Twelve hours after experiencing a traumatic closed fracture of the lower left tibia, a client reports pain, tingling, and diminished toe movement in the left foot. Which nursing problem has the highest priority based on this information?
Impaired comfort.
Impaired skin integrity.
Risk for infection related to traumatic fracture.
Risk for peripheral neurovascular dysfunction.
The Correct Answer is D
A. While impaired comfort is a concern, the priority is to address potential neurovascular compromise.
B. Impaired skin integrity is a concern but not the most immediate issue given the symptoms described.
C. Risk for infection is important but secondary to the acute concern of neurovascular function.
D. Risk for peripheral neurovascular dysfunction is the highest priority as it indicates potential compartment syndrome or other serious complications requiring urgent intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. While reassuring the client about visiting arrangements is supportive, it is not as critical for ensuring continuity of care.
B. Obtaining a detailed report from the transferring nurse is crucial to ensure all relevant information and the client’s wishes are communicated effectively.
C. Providing written information about end-of-life care is helpful but secondary to ensuring accurate communication of the client’s care preferences.
D. Marking the chart is important, but the immediate priority is ensuring the complete and accurate transfer of care information.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"}}
Explanation
Diazepam is a benzodiazepine that can be effective in managing symptoms of serotonin syndrome, including agitation and myoclonus. It can help reduce muscle rigidity and provide sedation.
Inducing paralysis is not appropriate in this scenario. The patient’s symptoms suggest serotonin syndrome or another type of stimulant intoxication, and paralysis could worsen the situation or mask underlying symptoms.
The patient has a high fever (102°F or 38.8°C) and significant diaphoresis. Cooling blankets can help manage hyperthermia and reduce body temperature.
The patient’s oxygen saturation is 97% on room air, indicating adequate oxygenation. There is no immediate need for supplemental oxygen at this time.
If the patient is suspected to have serotonin syndrome, which can be triggered by the use of certain antidepressants (particularly SSRIs), discontinuing the offending medication is crucial.
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