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 nurse should identify that caring for a client who has a new onset of chest pain is outside the scope of practice for an LPN. This is a complex and potentially life-threatening situation that requires the assessment and intervention of a registered nurse (RN) or other advanced practice provider.
b) Caring for a client who has a tracheostomy is within the scope of practice for an LPN.
c) Caring for a client who is receiving enteral feedings is within the scope of practice for an LPN.
d) Caring for a client who has urinary retention is within the scope of practice for an LPN.
Correct Answer is D
Explanation
d. Pinpoint pupils.
Explanation:
Opioid intoxication is characterized by various signs and symptoms, including central nervous system depression. One common manifestation of opioid intoxication is pinpoint pupils (miosis), which is caused by the effect of opioids on the pupillary constrictor muscles. The pupils become constricted and appear as small dots, hence the term "pinpoint."
The other options are not typical manifestations of opioid intoxication. Tachycardia (rapid heart rate) is more commonly associated with stimulant use rather than opioids. Mental alertness is typically reduced in cases of opioid intoxication, as opioids cause sedation and CNS depression. Hyperreflexia (exaggerated reflexes) is not a typical finding in opioid intoxication; instead, it may occur in withdrawal from certain substances such as alcohol or benzodiazepines.
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