Which assessment finding indicates to the nurse that the client who sustained a fractured femur in a motor vehicle accident is experiencing fat emboli syndrome?
Petechiae on the chest.
An edematous calf.
Elevated temperature.
Paresthesia distal to the fracture.
The Correct Answer is A
Choice A Reason
Petechiae on the chest are a classic sign of fat emboli syndrome (FES). FES is a rare but serious complication that can occur after a long bone fracture, such as a femur fracture. The petechiae result from small fat droplets that travel to the skin's capillaries and cause pinpoint hemorrhages. This symptom is part of the classic triad for FES, which includes respiratory distress, neurological symptoms, and a petechial rash.
Choice B Reason
While an edematous calf may be a concern for deep vein thrombosis or other complications following a fracture, it is not a specific indicator of FES. Edema in the calf could be due to various reasons, including local trauma from the fracture itself or immobilization.
Choice C Reason
An elevated temperature can be associated with many post-injury complications, including infection or inflammatory response. However, it is not specific to FES. While patients with FES may present with fever, it is not one of the primary diagnostic criteria.
Choice D Reason
Paresthesia distal to the fracture could indicate nerve damage or compartment syndrome, which are important to assess in a patient with a femur fracture. However, paresthesia is not a specific sign of FES. The neurological symptoms associated with FES are more generalized and often include confusion or altered mental status.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason
A blood pressure of 120/80 mmHg is considered within the normal range and is an ideal target for most individuals being treated for hypertension. This finding would not typically alert the nurse to a side effect of lisinopril.
Choice B Reason
Serum potassium of 5.5 mEq/L is higher than the normal range, which is typically between 3.5 and 5.0 mEq/L. Lisinopril can cause hyperkalemia, which is an elevated level of potassium in the blood. This is a known side effect of lisinopril, especially in clients with renal impairment, as it inhibits the renin-angiotensin-aldosterone system and reduces potassium excretion.
Choice C Reason
A heart rate of 80 beats per minute is within the normal range for adults, which is typically 60-100 beats per minute at rest. This finding would not alert the nurse to a side effect of lisinopril.
Choice D Reason
A respiration rate of 16 breaths per minute is within the normal range for adults, which is typically 12-20 breaths per minute at rest. This finding would not alert the nurse to a side effect of lisinopril.
Correct Answer is A
Explanation
Choice A reason:
Providing information about available community resources is crucial for ongoing support and assistance. These resources can offer counseling, medical follow-up, legal advice, and other services that may be needed after such a traumatic event. Community resources play a vital role in the recovery process, offering a network of support and specialized services tailored to the needs of sexual assault survivors.
Choice B reason:
While it is important to know when to return to the ED for follow-up care, this is typically not the primary content of discharge instructions. Follow-up care is usually managed by primary care providers or specialists rather than the ED unless there are specific complications or concerns that need to be addressed immediately.
Choice C reason:
The names and phone numbers of local attorneys may be provided, but this is not standard for all discharge instructions. Legal support is important, but the immediate focus post-discharge is often on the survivor's physical and emotional well-being. Attorneys specializing in defending rape victims can be a part of the community resources provided to the survivor.
Choice D reason:
The phone number of a battered women's shelter or safe house may be included in discharge instructions, especially if there is an immediate need for safe accommodation. However, this is not the only resource that should be provided, and it is not specific to all cases of sexual assault.
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