A nurse is caring for a client who has a full arm cast and reports a pain level of 8 on a scale of 0 to 10, which is unrelieved by pain medication.
Which of the following actions should the nurse plan to take first?
Check the circulation of the affected extremity.
Administer additional pain medication.
Reposition the affected extremity.
Document the findings.
The Correct Answer is A
Choice A rationale
Checking the circulation of the affected extremity is crucial because the greatest risk to the client is neuromuscular injury resulting from compartment syndrome. Compartment syndrome is a serious condition that occurs when there’s increased pressure within the muscles, leading to decreased blood flow, which can cause muscle and nerve damage. Early detection and intervention are essential to prevent permanent damage.
Choice B rationale
Administering additional pain medication might provide temporary relief, but it does not address the underlying issue of potential compartment syndrome. Pain unrelieved by medication is a key indicator of this condition, and addressing circulation is the priority.
Choice C rationale
Repositioning the affected extremity might help with comfort, but it does not address the potential for compartment syndrome. The primary concern is ensuring adequate blood flow to prevent tissue damage.
Choice D rationale
Documenting the findings is important for medical records, but it does not address the immediate risk of compartment syndrome. Immediate action to check circulation is necessary to prevent serious complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Silvery, white scales are a characteristic finding in psoriasis. Psoriasis is a chronic autoimmune condition that causes rapid skin cell turnover, leading to the buildup of scales and red patches on the skin.
Choice B rationale
Intense pain is not typically associated with psoriasis. While psoriasis can cause discomfort and itching, it is not usually described as intensely painful.
Choice C rationale
Unilateral lesions are not characteristic of psoriasis. Psoriasis typically presents with symmetrical lesions on both sides of the body.
Choice D rationale
Serous drainage is not a common finding in psoriasis. Psoriasis lesions are usually dry and scaly rather than exudative. .
Correct Answer is ["A","B","E"]
Explanation
Wound infection is a significant risk factor for dehiscence. Infections can weaken the wound edges and delay healing, increasing the likelihood of the wound reopening.
Choice B rationale
Obesity is a risk factor for dehiscence because excess adipose tissue can place additional stress on the wound, impair blood flow, and delay healing.
Choice C rationale
Altered mental status is not directly associated with an increased risk of dehiscence. While it may affect a patient’s ability to follow postoperative care instructions, it is not a primary risk factor.
Choice D rationale
Pain medication administration is not a risk factor for dehiscence. Pain management is essential for recovery and does not contribute to wound reopening.
Choice E rationale
Poor nutritional state is a risk factor for dehiscence because adequate nutrition is essential for wound healing. Malnutrition can impair the body’s ability to repair tissues and increase the risk of wound complications.
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