A nurse is caring for a group of adolescents. Which of the following findings should be reported to the provider immediately?
A client who has a burn injury to an estimated 5% of his leg and is crying
A client who has an ankle fracture reports a pain level increase from 3 to 5 after initial ambulation
A who is a client 1 day postoperative and has a temperature of 37.5° C (99.5° F)
A client's blood pressure changes from 112/60 mm Hg to 90/54 mm Hg when standing
The Correct Answer is D
D. A client's blood pressure changes from 112/60 mm Hg to 90/54 mm Hg when standing.
A significant drop in blood pressure when changing positions from lying to standing may indicate orthostatic hypotension, which can be a sign of dehydration, blood loss, or other underlying medical issues. This can be a cause for concern, especially if the client is an adolescent, as it may lead to decreased perfusion of vital organs and may require immediate medical attention.
The other options are as follows:
A. A client who has a burn injury to an estimated 5% of his leg and is crying - While it's essential to assess and address the client's pain and comfort, this finding does not indicate an immediate need for medical attention. Pain management and wound care can be addressed based on the severity of the burn and the client's pain level.
B. A client who has an ankle fracture reports a pain level increase from 3 to 5 after initial ambulation - This finding is concerning, and the nurse should notify the provider to reassess pain management and evaluate for potential complications related to the fracture. However, it may not require immediate medical attention unless there are signs of severe pain or complications.
C. A client who is 1 day postoperative and has a temperature of 37.5° C (99.5° F) - A slight increase in temperature in the immediate postoperative period may not be unusual and can be attributed to the normal inflammatory response after surgery. The nurse should continue monitoring the client's temperature and report any further changes or additional signs of infection or complications to the provider.
Overall, while all findings should be addressed and managed appropriately, the significant drop in blood pressure (option D) should be reported immediately due to the potential implications for the client's overall health and well-being.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
During a sickle cell crisis, the child experiences severe pain due to the sickled red blood cells blocking blood flow in the vessels, leading to tissue ischemia and infarction. Pain is the hallmark symptom of sickle cell crisis and can occur in various parts of the body, such as the abdomen, chest, back, joints, and extremities.
A. Constipation is not a common symptom of sickle cell crisis. It may be associated with other conditions but is not directly related to sickle cell crisis.
C. High fever is not a typical finding in sickle cell crisis. Fever may occur due to infections, which individuals with sickle cell disease are at increased risk of developing, but it is not a direct symptom of the crisis itself.
D. Bradycardia (slow heart rate) is not commonly associated with sickle cell crisis. Tachycardia (rapid heart rate) may occur in response to pain, but bradycardia is not a typical finding.
Correct Answer is B
Explanation
For a child with hemophilia experiencing a joint injury, the best home treatment and therapy would be elevation and the application of ice to the affected joint. This approach helps reduce swelling and minimize bleeding in the joint.
Option A (factor VIII concentrates) is a treatment for hemophilia but is typically administered intravenously to replace the deficient clotting factor in the blood. It is not a home treatment for joint injuries.
Option C (nonsteroidal anti-inflammatory drugs - NSAIDs) may be used to manage pain and inflammation, but they do not address the underlying bleeding disorder in hemophilia or directly treat joint injuries.
Option D (DDAVP - synthetic vasopressin) is used in some types of hemophilia to temporarily raise factor VIII levels, but it is not typically used for joint injuries or as a home treatment.
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