A client who has developed acute compartment syndrome from a compound fracture of the arm asks the nurse to define what this means. Based on an understanding of the condition, the nurse should explain that:
Bleeding and swelling cause increased pressure under the fascia.
Displaced bones compress nerves and vessels.
Blood supply to the bone is interrupted.
Compression of the muscle tissue restricts blood flow to the area.
The Correct Answer is A
Choice A Reason
Acute compartment syndrome occurs when bleeding or swelling within an enclosed bundle of muscles – known as a muscle compartment – leads to increased pressure. This pressure can impede blood flow to the body tissue and destroy function. The fascia, which is a tough layer of fibrous tissue, does not stretch easily, so any swelling or bleeding can quickly lead to increased pressure.
Choice B Reason
While displaced bones can compress nerves and vessels, this is not the primary mechanism of acute compartment syndrome. Displaced bones are more likely to cause direct injury or impingement, but compartment syndrome specifically refers to the pressure build-up within a muscle compartment that affects circulation and tissue viability.
Choice C Reason
Interruption of blood supply to the bone is a serious concern and can lead to conditions such as avascular necrosis. However, in the context of acute compartment syndrome, the primary issue is the pressure within the muscle compartment rather than direct disruption of blood supply to the bone.
Choice D Reason
Compression of muscle tissue can restrict blood flow to the area, which is a part of the pathophysiology of compartment syndrome. However, the compression is a result of increased pressure within the compartment, not the primary cause. The increased pressure is due to bleeding and swelling, which is why choice A is the most accurate description.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason:
Using accessory muscles while breathing is a sign of respiratory distress and indicates that the client is working harder to breathe. This is not a desired outcome of treatment and suggests that the asthma exacerbation is not under control.
Choice B Reason:
The ability to answer questions in full sentences suggests that the client's airway is not severely obstructed, which is a positive sign of effective asthma treatment. When asthma is well-controlled, individuals should not experience significant shortness of breath that limits their ability to speak.
Choice C Reason:
Diminished breath sounds can be a sign of severe airway obstruction and are not indicative of effective asthma treatment. Ideally, lung auscultation should reveal clear breath sounds without wheezing, indicating good air movement throughout the lungs.
Choice D Reason:
Restlessness and anxiety can be symptoms of hypoxia, a condition where the body or a region of the body is deprived of adequate oxygen supply. This is not a sign of effective asthma treatment and may indicate that the client's asthma is not well-managed.
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.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today