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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Correct Answer is B

Explanation

A. Driving the client to the nearest medical facility is not appropriate; professional emergency medical services are needed.

B. Notifying emergency management services ensures that the client receives professional medical evaluation and care immediately.

C. Providing water to test the gag reflex is not appropriate in an emergency situation and could pose a choking risk.

D. Performing carotid massage is not recommended and could worsen the condition; it is not a standard emergency procedure.

A. "Wear an eye patch on the right eye at all times." B. "Plan to relax in a hot tub spa each day." C. "Engage in a vigorous exercise program." D. "Implement a schedule to include periods of rest."

Correct Answer is D

Explanation

A. "Wear an eye patch on the right eye at all times.": This is not appropriate as wearing an eye patch continuously can cause strain on the other eye. It is generally recommended to alternate the eye patch between eyes to manage diplopia (double vision).
B. "Plan to relax in a hot tub spa each day.": This is inappropriate as heat can exacerbate MS symptoms, leading to increased fatigue and other symptoms.
C. "Engage in a vigorous exercise program.": This is inappropriate because vigorous exercise can cause excessive fatigue in individuals with MS. A moderate, well-balanced exercise program is more beneficial.
D. "Implement a schedule to include periods of rest.": This is appropriate as incorporating periods of rest helps manage fatigue, which is a common symptom in MS. It allows the client to balance activity and rest to avoid exacerbation of symptoms.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is shopping and finds a woman who has collapsed with right-sided weakness and slurred speech. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is presenting discharge instructions to a client who has multiple sclerosis (MS). The client reports symptoms of diplopia, dysmetria, and sensory change. Which of the following nursing statements are appropriate?

Correct Answer is D

Explanation

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