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
Explanation
A. Inspecting for the presence of clubbing is related to chronic respiratory or cardiac conditions, not ataxia.
B. Performing a Romberg's test evaluates balance and proprioception, which is important for assessing the ability to ambulate safely in a person with ataxia.
C. Observing for the presence of Kernig's sign is used to assess for meningeal irritation, not ataxia.
D. Checking the function of cranial nerve V is related to sensation and motor function of the jaw, not to assessing ambulation or balance.
Correct Answer is A
Explanation
A. Lateral segment of the right lower lobe is the correct answer because placing the client on the left side in Trendelenburg position promotes drainage from the right lower lobe’s lateral segment by using gravity to mobilize secretions.
B. Lateral segment of the left lower lobe would require the client to be positioned on the right side rather than the left.
C. Posterior segment of the right middle lobe would require the client to be positioned in a different way, typically supine with a slight Trendelenburg tilt.
D. Posterior segment of the right lower lobe would require a prone position in Trendelenburg, not left-side lying.
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