A nurse is collecting data on a client who has swelling of the lower leg. The nurse should identify that which of the following findings is a manifestation of compartment syndrome?
Affected extremity warm to touch
Moderate pain on the ankle of the affected extremity
Blanch time of 2 seconds in the toenail beds of the affected extremity
Palpation of a +1 dorsal pedal pulse of the affected extremity
The Correct Answer is B
A nurse collecting data on a client who has swelling of the lower leg should identify that moderate pain on the ankle of the affected extremity is a manifestation of compartment syndrome. Compartment syndrome is a painful condition that occurs when pressure within a muscle compartment increases to dangerous levels.
The other options are not typical symptoms of compartment syndrome.
a) An affected extremity being warm to touch is not a typical symptom of compartment syndrome.
c) A blanch time of 2 seconds in the toenail beds of the affected extremity is not a typical symptom of compartment syndrome.
d) Palpation of a +1 dorsal pedal pulse of the affected extremity is not a typical symptom of
compartment syndrome.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The action by the AP that indicates an understanding of the procedure is elevating the client's legs before applying the stockings. Elevating the legs can help reduce swelling and make it easier to apply the stockings.
Option b is incorrect because instructing the client to dorsiflex their feet while applying the stockings may not be necessary.
Option c is incorrect because massaging the client's legs before applying the stockings may not be necessary or appropriate.
Option d is incorrect because folding the top of the stockings over after applying them may not be necessary or appropriate.
Correct Answer is C
Explanation
The statement by the client that indicates an understanding of the teaching is "I plan to take water aerobics classes at the gym near my house." Exercise is an important part of managing osteoarthritis, and water aerobics is a low-impact exercise that can help improve joint mobility and reduce pain.
Option ais incorrect because applying cold compresses may not be the most effective way to manage pain associated with osteoarthritis. Heat therapy is often more effective for this condition.
Option b is incorrect because limiting purine intake in the diet is recommended for clients with gout, not osteoarthritis.
Option d is incorrect because ibuprofen can be an effective pain reliever for clients with osteoarthritis.
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