A nurse is caring for a client in an orthopedic unit.
Drag words from the choices below to fill in each blank in the following sentence.
The client is at risk for developing
The Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"B"}
- Deep vein syndrome: This is not a recognized condition. The intended term may have been deep vein thrombosis (DVT), which is a valid orthopedic complication, but the clinical findings in this scenario point more urgently toward compartment syndrome and infection.
- Osteomyelitis: The client has an open fracture with drainage from the splint, a significantly elevated WBC count (28,000/mm³), and a high fever (38.9°C / 102°F). These findings suggest the development of a bone infection (osteomyelitis), especially in the context of recent surgery and internal fixation.
- Fat embolism syndrome: While fat embolism is a risk with long bone fractures, this client is not displaying key hallmark signs such as respiratory distress, petechiae, or altered mental status. The findings are more consistent with infection and circulatory compromise.
- Compartment syndrome: The client has classic signs including cool foot, numbness, inability to move toes, absent pulses, delayed capillary refill, and increased pain. These are hallmark signs of neurovascular compromise from compartment syndrome, a surgical emergency.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","E"]
Explanation
A. The client engages in quiet activities in their room. While this may seem positive, it is not a reliable indicator of improvement in this context. It could suggest withdrawal or sedation rather than clinical stabilization. Further assessment would be needed to determine its significance.
B. The client slept 5 hr the previous night. This is a clear sign of improvement. The client had not slept for 2 days previously, and sleep is one of the first indicators of recovery in clients experiencing mania. Restorative sleep helps stabilize mood and reduce disorganized thinking.
C. The client takes 2 short naps during the day. Napping indicates the client is able to rest voluntarily, which contrasts with their earlier constant movement and hyperactivity. This suggests reduced mania-related agitation and increased capacity for rest.
D. The client appears to listen to unseen others. This behavior reflects ongoing hallucinations, which indicate that the client is still experiencing active psychosis. This is not an improvement and suggests further monitoring and treatment adjustment may be needed.
E. The client consumes 8 oz of high-calorie fluids each hour. Adequate nutrition and hydration are key components of recovery, especially since the client had been unable to recall their last meal and showed signs of dehydration. This is a positive sign of improved self-care and physical stability.
Correct Answer is B
Explanation
A. Have the client store smaller tanks under his bed. Oxygen tanks should never be stored in enclosed or confined spaces such as under a bed due to the risk of fire and poor ventilation, which can increase the danger of oxygen accumulation.
B. Place the oxygen tank away from curtains or drapes. This is essential to reduce the risk of fire. Oxygen supports combustion, so keeping the tank away from flammable materials like curtains helps ensure a safe home environment.
C. Store the oxygen tank wrench in a locked cabinet. The wrench should be kept accessible, not locked away, to allow quick adjustments or shut-off in case of emergency. Immediate access is a priority in safe oxygen use.
D. Ensure that the client checks the gauge weekly. The oxygen tank gauge should be monitored more frequently than once a week to avoid running out of oxygen unexpectedly, especially in clients with chronic respiratory conditions like COPD.
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