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 D
Explanation
A. Nasal congestion is not a primary sign of autonomic dysreflexia, though it can be a symptom of other conditions.
B. A severe headache can be a symptom of autonomic dysreflexia but is not the sole indicator of the condition.
C. Elevated blood pressure can be a result of autonomic dysreflexia but is not necessarily an indication of risk without other symptoms.
D. A distended bladder is a common trigger for autonomic dysreflexia in clients with a spinal cord injury at or above T-6, making it a key indicator for monitoring.
Correct Answer is ["250"]
Explanation
- Total volume of IV fluid: 2000 mL
- Total time for infusion: 8 hours
Infusion rate: 2000/8 = 250ml/hr
=250
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
