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: Intubation and mechanical ventilation may be needed if the respiratory muscles are affected by GBS, but this is not a routine intervention at this stage.
Choice B rationale: One of the main treatments of GBS is IV immunoglobulin therapy (IVIG), which involves infusing antibodies from donated blood plasma to block the harmful immune response that damages the nerves. Sandoglobulin is one of the brand names of IVIG used for GBS. IVIG can help shorten the duration and severity of the disease, and improve the recovery rate.
Choice C rationale: Methylprednisolone is a corticosteroid that can reduce inflammation, but it is not recommended for GBS, as it may worsen the condition or increase the risk of infection.
Choice D rationale: NG feeding tube may be required if the patient has difficulty swallowing, but this is also not a standard intervention at this time.
Correct Answer is C
Explanation
Choice A rationale: Low blood pressure sensed by baroreceptors in the kidneys would stimulate the renin-angiotensin-aldosterone system, which regulates blood pressure and sodium balance.
Choice B rationale: Low osmolality sensed by osmoreceptors in the kidneys would
indicate that the body has excess water and needs to excrete it, which would inhibit ADH release.
Choice C rationale: ADH, or antidiuretic hormone, is a peptide hormone that regulates the water balance in the body. It is released from the posterior pituitary gland in response to signals from the hypothalamus. When the plasma osmolarity, or the concentration of solutes in the blood, is high, it means that the body is dehydrated and needs to conserve water. The osmoreceptors in the hypothalamus detect this change and stimulate the release of ADH, which acts on the kidneys to increase water
reabsorption and decrease urine output. This helps to lower the plasma osmolarity and restore the water balance.
Choice D rationale: High concentration of potassium sensed by chemoreceptors in the carotid body would affect the acid-base balance and respiratory rate, but not ADH
release.
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