A nurse is assessing for early signs of compartment syndrome for a client who has a short-leg fiberglass cast. Which of the following findings should the nurse expect?
Intense pain with movement
Bounding distal pulses
Erythema of the toes
Capillary refill less than 2 seconds
The Correct Answer is A
Compartment syndrome is a condition in which increased pressure within a confined space compromises blood flow and tissue perfusion, leading to ischemia and necrosis. It can occur after trauma, fracture, or casting of an extremity. The early signs of compartment syndrome include intense pain with movement that is not relieved by analgesics or elevation, paresthesia, pallor, and decreased sensation and motor function of the affected limb. The late signs include absent distal pulses, cyanosis, coldness, and paralysis. Therefore, option A is correct.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
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Correct Answer is D
Explanation
The client should wash their perineal area twice a day with antimicrobial soap to prevent infection and irritation. This is especially important for clients who have an impaired immune system due to chemotherapy, as they are more susceptible to infections and complications.
Correct Answer is B
Explanation
A 2-g sodium diet means limiting sodium intake to no more than 2000 mg per day. Sodium is found in salt and many processed foods, such as canned vegetables, soups, sauces, and baked goods. Sodium can cause fluid retention and worsen heart failure symptoms, such as shortness of breath, swelling, and fatigue. Therefore, the client should avoid adding salt or salt substitutes (such as baking soda) to their foods and choose fresh or frozen vegetables over canned ones. Lemon juice is a low-sodium alternative that can add flavor to foods without increasing sodium intake.
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