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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A reason:

While polyhydramnios can be associated with congenital anomalies or fetal distress, it is not a direct indication of these conditions. Polyhydramnios refers specifically to the excessive accumulation of amniotic fluid. Congenital anomalies may lead to polyhydramnios if they affect the fetus's ability to swallow and process amniotic fluid normally, but the presence of polyhydramnios alone does not confirm these conditions.

Choice B reason:

Elevated levels of alpha-fetoprotein (AFP) in the amniotic fluid can be indicative of neural tube defects or other fetal abnormalities, but they are not a defining characteristic of polyhydramnios. Normal AFP levels in amniotic fluid at 15 to 21 weeks' gestation range from 10 to 150 ng/ml. Polyhydramnios is diagnosed based on the volume of amniotic fluid, not the AFP levels.

Choice C reason:

Carrying more than one fetus can lead to an increased amount of amniotic fluid, potentially resulting in polyhydramnios. However, the diagnosis of polyhydramnios itself does not imply a multiple gestation pregnancy. It simply indicates that there is more amniotic fluid than usual.

Choice D reason:

Polyhydramnios is defined as an excessive amount of amniotic fluid. It is typically diagnosed when the amniotic fluid index (AFI) exceeds 24 cm or the single deepest pocket (SDP) measures more than 8 cm. This condition can occur due to various reasons, including fetal anomalies, maternal diabetes, and other medical conditions.

A. The client is free of chest pain and dyspnea. B. The client describes the importance of increasing fluid intake. C. The client increases aerobic exercises to promote endurance. D. The client's acute pain is controlled at 3 on a standard pain scale.

Correct Answer is ["A","B","D"]

Explanation

Choice A reason:
Being free of chest pain and dyspnea is a significant indicator of successful nursing intervention in a sickle cell crisis. Chest pain and dyspnea can occur due to acute chest syndrome, a life-threatening complication of sickle cell disease characterized by vaso-occlusion in the pulmonary microcirculation. Effective pain management and oxygen therapy can alleviate these symptoms, reflecting improved respiratory function and gas exchange.

Choice B reason:
Educating the client on the importance of increasing fluid intake is crucial in managing sickle cell crisis. Adequate hydration helps to reduce blood viscosity and prevent sickling of red blood cells, which can lead to vaso-occlusive episodes. When a client verbalizes understanding and the importance of hydration, it demonstrates the effectiveness of patient education and the client's engagement in self-care.

Choice C reason:
While increasing aerobic exercises may promote endurance, it is not typically a short-term outcome measure for a sickle cell crisis. Exercise must be approached with caution in these clients, as it can increase the risk of a vaso-occlusive crisis due to dehydration and increased oxygen demand during a sickle cell crisis.

Choice D reason:
Control of acute pain to a level of 3 on a standard pain scale indicates successful pain management, a primary goal in the treatment of sickle cell crisis. Pain in sickle cell crisis is due to ischemia from obstructed blood flow by sickled cells. Effective analgesic administration and pain management strategies are essential to achieve this outcome.

Choice E reason:
A leukocyte count of 18,000/mm³ is above the normal range (4,500 to 11,000/mm³) and may indicate an infection or inflammation, which are common complications of sickle cell disease. However, this is not a direct outcome of nursing interventions aimed at managing a sickle cell crisis and thus is not a correct choice.

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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:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who was admitted to the maternity unit at 38 weeks of gestation and who is experiencing polyhydramnios. The nurse should understand that this diagnosis means which of the following?

Correct Answer is D

Explanation

How can the nurse determine that the outcomes of nursing interventions have been successful for the client diagnosed with a sickle cell crisis? (SELECT ALL THAT APPLY)

Correct Answer is ["A","B","D"]

Explanation

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