A nurse in an emergency department is caring for a 60-year-old client.

Exhibits

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.

Answer and Explanation

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

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. Neurologic deficits increasing over 2 weeks are more characteristic of subdural hematomas, not epidural hematomas.
B. A change in the level of consciousness that develops over 48 hours is typical of subdural hematomas.
C. An epidural hematoma often presents with a brief period of lucidity followed by a rapid decline in consciousness due to arterial bleeding.
D. Cognitive perception that decreases over several months post-injury is not typical of epidural hematomas, which generally cause acute and rapid changes.

A. Flex the client's hip. B. Hyperextend the client's neck. C. Provide warming measures for the client. D. Adjust the client's head of bed.

Correct Answer is D

Explanation

A. Flex the client’s hip is incorrect. Flexing the hip can increase intra-abdominal pressure and potentially increase intracranial pressure.

B. Hyperextend the client’s neck is incorrect. Hyperextension of the neck can interfere with venous return from the brain and increase ICP.

C. Provide warming measures for the client is incorrect. Warming measures are not indicated for a low CPP; maintaining normothermia is important, but warming is not the priority action.

D. Adjust the client’s head of bed is correct. Elevating the head of the bed helps reduce ICP and improves cerebral perfusion by promoting venous outflow.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has an epidural hematoma. Which of the following manifestations should the nurse expect?

Correct Answer is C

Explanation

A nurse on the intensive care unit is caring for a client who has severe traumatic brain injury and a cerebral perfusion pressure (CPP) of 59 mm Hg. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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