A 16-year-old male presents to the emergency department with right knee pain.
Complete the statement below:
The client is at risk for and the nurse should ?
Fracture/immobilized the extremity
Contracture / obtain a prescription for acetaminophen
Sprain/ raise the leg
Dislocation/apply heat to the area
The Correct Answer is A
Choice A rationale: Considering the mechanism of injury, pain severity, tenderness, swelling, and ecchymosis, there is a high suspicion of a fracture. Immobilization is essential to prevent further injury and reduce pain.
Choice B rationale: Contracture is less likely in this acute injury scenario. Acetaminophen might manage pain, but it doesn't address the risk factor.
Choice C rationale: A sprain is less likely given the severity of pain and the mechanism of injury. Raising the leg doesn't address the risk of a suspected fracture.
Choice D rationale: Dislocation doesn't align with the reported symptoms. Applying heat could potentially worsen inflammation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale: The 42-yr-old patient with secondary amenorrhea may have menopause, pregnancy, or a hormonal disorder. This is less urgent compared to the 19- year old patient.
Choice B rationale: This patient may have toxic shock syndrome, which is a life- threatening complication of tampon use that can cause organ failure and shock. The nurse should assess the patient's vital signs, remove the tampon, and initiate fluid resuscitation and antibiotic therapy.
Choice C rationale: This patient may have an infection or a complication of the balloon thermotherapy, which is a procedure to destroy the endometrial lining of the uterus and is not an emergency compared to the 19 year old.
Choice D rationale: This patient may have a displacement or perforation of the IUD, which is a contraceptive device that releases progestin into the uterus. However, this is not urgent compared to the 19 year old.
Correct Answer is D
Explanation
Choice A rationale: Gastrointestinal reflux disease is not typically a contraindication for sumatriptan.
Choice B rationale: Mild emphysema is not typically a contraindication for sumatriptan.
Choice C rationale: Hyperthyroidism is not typically a contraindication for sumatriptan.
Choice D rationale: Sumatriptan, a medication used for migraines, may elevate blood pressure, so it would be questionable for a client with hypertension.
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