The nurse is continuing to care for the child.
Complete the following sentence by using the lists of options.
The child is at highest risk for developing
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}
Rationale for Correct Choices:
- Compartment Syndrome: Compartment syndrome is a limb-threatening condition that occurs when increased pressure within a muscle compartment impairs circulation and nerve function. The child has a nondisplaced fracture of both the radius and ulna, along with edema, ecchymosis, and fingers that are cool to touch, all of which are early signs of compromised perfusion.
- Tingling Sensation: Tingling (paresthesia) is an early neurological sign of impaired sensory function often seen in the early stages of compartment syndrome. This child verbalizes a mild tingling in the fingers, which indicates nerve compression due to increased pressure within the forearm compartments.
Rationale for Incorrect Choices
- Paresthesia: Tingling is the hallmark symptom of paresthesia, but paresthesia is a symptom, not a disease process. The nurse must determine the underlying cause of the altered sensation, which in this situation is likely compartment syndrome.
- Deep Vein Thrombosis (DVT): DVT typically presents with unilateral leg swelling, warmth, pain, and sometimes redness—not forearm injury symptoms. The child has a forearm fracture and bruises on the lower extremities in different healing stages, but there's no localized swelling, erythema, or immobility in the legs to support a DVT diagnosis.
- Pain Level: A pain score of 4 out of 10 is not severe enough to support compartment syndrome or any acute vascular crisis alone. Pain that is out of proportion to the injury and unrelieved by medication would raise concern.
- Mobility: The child is ambulatory and able to move their fingers and limbs, which reduces the likelihood of venous stasis a major risk factor for DVT. In the absence of prolonged immobility or systemic hypercoagulability, there is minimal reason to suspect a thrombotic event based on mobility alone.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is []
Explanation
Rationale for Correct Choices
- Heart failure: The client’s symptoms bilateral crackles, +3 lower extremity edema, cool limbs with weak pulses, an S3 heart sound, and elevated BNP are classic signs of decompensated heart failure with volume overload and poor perfusion.
- Educate the client about sodium restriction: Sodium contributes to fluid retention and increased cardiac workload. Dietary sodium restriction is crucial in preventing fluid overload, thus reducing exacerbations of heart failure symptoms such as edema and dyspnea.
- Obtain a prescription for a diuretic: Diuretics like furosemide relieve volume overload by promoting fluid excretion. They help decrease pulmonary congestion, improve oxygenation, and reduce peripheral edema in heart failure patients.
- Daily weight: Monitoring weight helps detect subtle changes in fluid balance. A sudden weight gain of 2–3 pounds in 24 hours may signal worsening heart failure and the need for diuretic adjustment.
- Blood pressure: Blood pressure monitoring provides insight into cardiac output and guides medication titration. Both hypertension and hypotension can worsen outcomes in clients with heart failure.
Rationale for Incorrect Choices
- Endocarditis: This condition presents with fever, new or changing murmurs, petechiae, or positive blood cultures. The absence of infection signs and the presence of systemic fluid overload point away from endocarditis.
- Aortic stenosis: Typical signs include exertional dyspnea, syncope, chest pain, and a harsh systolic murmur not crackles, edema, or elevated BNP. This client’s profile better matches heart failure.
- Mitral stenosis: This condition may cause pulmonary congestion but often presents with a diastolic murmur and atrial fibrillation, which are not described here.
- Administer antibiotics as prescribed: Without clinical or laboratory signs of infection (fever, leukocytosis, or positive cultures), antibiotics are not appropriate for heart failure.
- Prepare the client for cardioversion: Cardioversion is used for arrhythmias like atrial fibrillation with rapid ventricular response. The client has a normal apical pulse and no dysrhythmia signs.
- Educate the client about valve replacement: Valve surgery is not indicated unless diagnostic findings confirm severe valvular disease. No murmur or echo data is provided here.
- Skin lesions: These are associated with endocarditis, not heart failure. Findings like Janeway lesions or Osler nodes are not reported in this case.
- Blood cultures: Indicated when bacteremia or endocarditis is suspected. Heart failure without infection signs does not warrant blood cultures.
- Fever: The client is afebrile, making infection less likely. Fever is not a feature of uncomplicated heart failure and does not need monitoring here.
Correct Answer is ["A","B","E"]
Explanation
Rationale:
A. Anemia: End-stage kidney disease reduces erythropoietin production by the kidneys, which impairs red blood cell formation in the bone marrow. This often leads to normocytic, normochromic anemia in affected clients.
B. Oliguria: As kidney function declines, urine output diminishes. Oliguria, defined as urine output less than 400 mL/day, is a common clinical feature of advanced kidney failure due to decreased glomerular filtration.
C. Hypotension: Clients with end-stage kidney disease more commonly experience hypertension due to fluid overload and impaired renin-angiotensin-aldosterone regulation. Hypotension may occur during dialysis but is not a typical baseline finding.
D. Bradypnea: Respiratory compensation for metabolic acidosis in kidney disease typically results in tachypnea, not bradypnea. The body increases respiratory rate to blow off excess CO₂ and correct the acid-base imbalance.
E. Edema: Impaired fluid excretion leads to sodium and water retention, resulting in peripheral, facial, or pulmonary edema. This is a hallmark feature of volume overload in chronic kidney disease.
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