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 ["A","B","C","E"]

Explanation

A. Slurred speech can indicate increased ICP as it may affect neurological function.

B. Headache is a common symptom of increased ICP.

C. Pupillary changes can indicate increased ICP, affecting cranial nerve function.

D. Neck pain and stiffness are more associated with meningitis or other conditions, not specifically increased ICP.

E. Disorientation can be a sign of increased ICP affecting brain function.

A. Engage in repetitive tasks, even when joints are inflamed, to keep the joints mobile. B. Press water from a sponge rather than wringing it. C. Finish weekly household tasks within 1 or 2 days. D. Turn doorknobs using a clockwise motion.

Correct Answer is B

Explanation

A. Engage in repetitive tasks, even when joints are inflamed, to keep the joints mobile is not recommended; rest and joint protection are important during inflammation.

B. Press water from a sponge rather than wringing it is a good strategy to avoid straining the joints.

C. Finish weekly household tasks within 1 or 2 days may lead to increased stress on the joints; tasks should be spread out to avoid exacerbating symptoms.

D. Turn doorknobs using a clockwise motion does not have specific benefits for managing rheumatoid arthritis; using adaptive devices is generally recommended.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is ["A","B","C","E"]

Explanation

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Correct Answer is B

Explanation

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