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 ["B","C","D","E"]
Explanation
A. Ecchymosis indicates bruising but is not a primary parameter for assessing neurovascular status.
B. Skin integrity is important to monitor for any signs of breakdown or infection.
C. Temperature helps assess for adequate blood flow and potential complications.
D. Color of the extremity indicates blood flow and can show signs of compromised circulation.
E. Sensation checks for nerve damage or impaired circulation.
Correct Answer is B
Explanation
A. Fluids should not be restricted; adequate hydration is necessary to help flush the contrast dye used during the procedure out of the client's system.
B. Performing neurovascular checks with vital signs is essential to monitor for complications such as bleeding, hematoma, or compromised circulation to the extremity.
C. The client should avoid range-of-motion exercises to the lower extremities immediately following the procedure to prevent disruption of the femoral artery site.
D. The client should remain on bed rest for several hours following the procedure to reduce the risk of bleeding at the catheter insertion site.
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