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 B

Explanation

A. Placing the client in a supine position can increase ICP. The head of the bed should be elevated 30-45 degrees to promote venous drainage from the head.
B. Using log rolling to reposition the client helps to maintain spinal alignment and prevent increases in ICP.
C. A warming blanket is not typically necessary unless the client is hypothermic; it does not directly affect ICP management.
D. Instructing the client to cough and deep breathe can increase ICP and should be avoided in clients with elevated ICP.

A. Granulocytes B. RBC C. WBC D. Platelets

Correct Answer is D

Explanation

A. Granulocytes are typically not decreased in ITP; they are more relevant for infections or bone marrow conditions.

B. RBC levels are not typically affected in ITP; the primary issue is with platelet counts.

C. WBC levels are generally normal in ITP, though they can vary in other conditions.

D. Platelets are expected to be decreased in ITP, which is characterized by an immune-mediated destruction of platelets.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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