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The nurse is continuing to care for the child.

Exhibits

Complete the following sentence by using the lists of options.

The child is at highest risk for developing

as evidenced by the child's .
Answer and Explanation

The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}

Rationale for Correct Choices:

  • Compartment Syndrome: Compartment syndrome is a limb-threatening condition that occurs when increased pressure within a muscle compartment impairs circulation and nerve function. The child has a nondisplaced fracture of both the radius and ulna, along with edema, ecchymosis, and fingers that are cool to touch, all of which are early signs of compromised perfusion.
  • Tingling Sensation: Tingling (paresthesia) is an early neurological sign of impaired sensory function often seen in the early stages of compartment syndrome. This child verbalizes a mild tingling in the fingers, which indicates nerve compression due to increased pressure within the forearm compartments.

Rationale for Incorrect Choices

  • Paresthesia: Tingling is the hallmark symptom of paresthesia, but paresthesia is a symptom, not a disease process. The nurse must determine the underlying cause of the altered sensation, which in this situation is likely compartment syndrome.
  • Deep Vein Thrombosis (DVT): DVT typically presents with unilateral leg swelling, warmth, pain, and sometimes redness—not forearm injury symptoms. The child has a forearm fracture and bruises on the lower extremities in different healing stages, but there's no localized swelling, erythema, or immobility in the legs to support a DVT diagnosis.
  • Pain Level: A pain score of 4 out of 10 is not severe enough to support compartment syndrome or any acute vascular crisis alone. Pain that is out of proportion to the injury and unrelieved by medication would raise concern.
  • Mobility: The child is ambulatory and able to move their fingers and limbs, which reduces the likelihood of venous stasis a major risk factor for DVT. In the absence of prolonged immobility or systemic hypercoagulability, there is minimal reason to suspect a thrombotic event based on mobility alone.


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Related Questions

Correct Answer is B

Explanation

Rationale:

A. Autonomy: Autonomy involves respecting a client’s right to make their own healthcare decisions. While important, this scenario concerns unequal treatment rather than limiting the clients’ decision-making rights.

B. Justice: Justice refers to fairness and equity in the distribution of healthcare resources. Providing supplies to one client based on insurance status while denying them to another reflects unequal and unethical treatment, violating the principle of justice.

C. Beneficence: Beneficence means acting in the best interest of the client by promoting well-being. Although the insured client is benefitting, failing to support the uninsured client equally undermines the overall intent to do good for all clients.

D. Nonmaleficence: Nonmaleficence is the obligation to do no harm. While denying supplies could lead to harm, the primary ethical breach in this situation lies in the unfair distribution of care, which relates more directly to justice.

Correct Answer is {"dropdown-group-1":"E","dropdown-group-2":"D"}

Explanation

Rationale for Correct Choices

  • Intravenous antibiotics: The client presents with uterine tenderness, dark foul-smelling lochia, a mildly elevated temperature, and an elevated WBC count, all of which point to endometritis, a common postpartum infection. The first-line treatment for endometritis is broad-spectrum IV antibiotics to prevent complications like sepsis.
  • Increase in daily fluid intake: Infection and fever can increase fluid loss through insensible means, and fluids support circulation, renal function, and antibiotic delivery. Encouraging increased fluid intake also helps address dehydration from fever and supports healing and lactation.

Rationale for Incorrect Choices

  • Kleihauer-Betke test: This test detects fetal-to-maternal hemorrhage and is used in trauma or suspected placental abruption in Rh-negative mothers. There is no indication of bleeding or Rh incompatibility in this case, so it is not appropriate here.
  • Tocolytic medication: Tocolytics are used to suppress uterine contractions in preterm labor. This client is postpartum and has no signs of preterm labor or uterine hyperstimulation, so this medication is not warranted.
  • Intrauterine tamponade balloon: This device is used for severe postpartum hemorrhage due to uterine atony that doesn’t respond to medical treatment. The client has moderate lochia but no signs of active hemorrhage or hemodynamic instability, so it is not indicated.

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