A nurse in the emergency department is assess a client who was in a motor-vehicle crash 2
days ago and sustained fractures to his tibia, ulna, and several ribs. The client is now
disoriented to time and place, has a SaO2 of 87%, and the nurse notes generalized petechiae
on the client's skin. Which of the following complications should the nurse suspect? - ANS - Fat
embolism syndrome
*The nurse should identify the triad of neurologic changes, petechial rash, and hypoxemia as
findings of fat embolism syndrome. Risk factors include multiple fractures and fracture of a long
bone. Male clients are also at greater risk. The manifestations occur when fat globules occlude
small blood vessels.
\A nurse in the emergency department is preparing to discharge a client following a Grad II
(moderate) ankle sprain. Which of the following instructions should the nurse plan to give the
client? - ANS - Apply cold compresses to the extremity intermittently
*Cold minimizes swelling and erythema to the affected area. Therefore, the nurse should
instruct the client to apply cold compresses for no more than 20 min at a time.
\A nurse is assessing a client who is 24 hr postoperative following an above-the-elbow
amputation. Which of the following findings should the nurse identify as the priority? - ANS -
Report of muscle spasms
*The nurse should consider Maslow's hierarchy of needs, which includes five levels of priority.
The first level consists of physiological needs; the second level consists of safety and security
needs; the third level consists of love and belonging needs; the fourth level consists of personal
achievement and self-esteem needs; and the fifth level consists of achieving full potential and
the ability to problem solve and cope with life situations. When applying Maslow's hierarchy of
needs priority-setting framework, the nurse should review physiological needs first. The nurses
should then address the client's needs by following the remaining four hierarchal levels. It is
important, however, for the nurse to consider all contributing client factors, as higher levels of
the pyramid can compete with those at the lower levels, depending on the specific client
situation. The fourth level of Maslow's hierarchy of needs includes usefulness, self-worth,
self-confidence in fulfilling self-esteem needs. Therefore, the nurse should identify the report of
muscle spasms, a physiological need, as the priority client finding.
\A nurse is assessing a client who is 48 hr postoperative following open reduction and internal
fixation of a fractured tibia. Which of the following findings should the nurse report to the
provider? - ANS - Toes cold to the touch
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