A nurse is caring for an older adult client who had a femoral head fracture 24 hours ago and is in skin traction. The client reports shortness of breath and dyspnea. The nurse should suspect that the client has developed which of the following complications?
Pneumothorax
Pneumonia
Airway obstruction
Fat embolism
The Correct Answer is D
Choice A reason:
Pneumothorax, a collapsed lung, can indeed cause shortness of breath and dyspnea. However, it is typically associated with a sudden onset of these symptoms following a chest injury or spontaneously in the case of a ruptured air blister. In the context of a femoral head fracture, pneumothorax is less likely unless there was additional trauma to the chest area.
Choice B reason:
Pneumonia is an infection of the lungs that leads to inflammation of the air sacs, causing them to fill with fluid or pus. Symptoms include cough with phlegm, fever, chills, and difficulty breathing. While pneumonia could cause dyspnea, it usually develops due to an infectious process rather than directly from a femoral head fracture.
Choice C reason:
Airway obstruction involves a blockage that prevents air from passing freely to the lungs. It can be caused by foreign objects, swelling due to allergic reactions, or other medical conditions. The symptoms of airway obstruction include difficulty breathing, wheezing, and potential changes in skin color. However, airway obstruction is not commonly a direct complication of a femoral head fracture.
Choice D reason:
Fat embolism syndrome is a serious condition that occurs when fat globules enter the bloodstream and lodge within the pulmonary vasculature, leading to respiratory distress. It is a known complication following long bone fractures, such as the femur, and presents with symptoms like shortness of breath, hypoxemia, and neurological manifestations. Given the recent femoral head fracture and the symptoms reported, fat embolism syndrome is the most likely diagnosis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
Asking questions about the information on her postoperative care pamphlet is a positive behavior indicating that the client is proactive in understanding her care and recovery process. It shows engagement and a desire to comply with medical advice, which is beneficial for recovery.
Choice B reason:
Refusing to look at the dressing or surgical incision may indicate psychological distress and difficulty in accepting the physical changes following a mastectomy. This behavior can be a sign of avoidance and a potential struggle with body image and the emotional impact of breast loss. It's important for healthcare providers to recognize this as a call for psychological support and possible referral to counseling services.
Choice C reason:
Performing arm exercises once or twice a day is typically recommended as part of the postoperative care after a mastectomy to prevent stiffness and improve mobility. This behavior suggests that the client is following postoperative instructions and actively participating in her recovery.
Correct Answer is B
Explanation
Choice A reason:
Purulent drainage at the intravenous site access site would indicate a more severe infection, possibly grade 3 or 4 on the Infusion Nurses Society's phlebitis scale. This would be associated with more advanced symptoms such as pus formation, which is not characteristic of grade 1 phlebitis.
Choice B reason:
Redness at the intravenous access site with pain is indicative of grade 1 phlebitis according to the Infusion Nurses Society's phlebitis scale. This grade is characterized by erythema and possible pain at the site of the IV insertion, without more severe symptoms such as swelling or streak formation.
Choice C reason:
Red streaks on the affected extremity suggest a progression of the inflammatory response, potentially indicating a higher grade of phlebitis, such as grade 2 or 3. This symptom suggests that the inflammation is spreading along the vein, which is more serious than grade 1 phlebitis.
Choice D reason:
A palpable venous cord in the affected extremity would also suggest a more severe form of phlebitis, likely grade 3. This occurs when a thrombus forms along with inflammation of the vein, leading to a palpable cord-like structure.
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