A nurse in an emergency department is caring for a 60-year-old client.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.
The Correct Answer is []
1. Condition: Acute Compartment Syndrome
Justification: The presence of severe pain, swelling, numbness, and a weak radial pulse along with delayed capillary refill are classic signs of acute compartment syndrome. Immediate surgical intervention (fasciotomy) is necessary to relieve the pressure within the muscle compartments.
2. Actions to Take
Prepare for Fasciotomy:
Justification: This surgical procedure will relieve the internal pressure causing the symptoms.
Request Prescription for Pain Medication:
Justification: Adequate pain management is important for client comfort and can also indicate response to treatment.
3. Parameters to Monitor
Neurovascular Status:
Justification: Monitoring for further deterioration of symptoms such as worsening numbness or weak pulses is essential.
WBC Count:
Justification: Helps in the broader assessment of possible infection, though not directly related to acute compartment syndrome
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Comminuted is correct. A comminuted fracture occurs when the bone breaks into several pieces, which matches the description of the tibia being splintered into multiple fragments.
B. Impacted is incorrect. An impacted fracture occurs when the ends of the bone are driven into each other.
C. Transverse is incorrect. A transverse fracture occurs in a straight line across the bone shaft.
D. Oblique is incorrect. An oblique fracture occurs at an angle across the bone shaft.
Correct Answer is B
Explanation
A. Radiofrequency catheter ablation is incorrect. This is a long-term treatment for arrhythmias but not for immediate management of VT.
B. Defibrillation is correct. Defibrillation is used for pulseless ventricular tachycardia or ventricular fibrillation to restore a normal heart rhythm.
C. CPR is incorrect. CPR is performed if the patient is unresponsive and pulseless, not as the first-line intervention for VT.
D. Elective cardioversion is incorrect. Elective cardioversion is used for stable arrhythmias such as atrial fibrillation, not for immediate VT treatment.
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