A nurse is completing a neurovascular check for a client who had an open reduction internal fixation surgery. Which of the following findings should the nurse identify as possible manifestations of compartment syndrome? (Select all that apply)

Absence of pulse

Altered sensation of the toes

Cool skin

Pain relieved by narcotics

Capillary refill 1 second

Answer and Explanation

Correct Answer : A,B,C

The nurse should identify the absence of pulse, altered sensation of the toes, and cool skin as possible manifestations of compartment syndrome. Compartment syndrome is a serious condition that can occur following surgery or injury. It is characterized by increased pressure within a muscle compartment that can lead to decreased blood flow and nerve damage.

Pain relieved by narcotics and capillary refill of 1 second are not manifestations of compartment syndrome. Pain relieved by narcotics is a normal response to pain medication. A capillary refill of 1 second is within the normal range and does not indicate compartment syndrome.

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Correct Answer is C

Explanation

An appropriate nursing action for a client who is restless following a traumatic brain injury with increased intracranial pressure is to reduce stimuli. This can help calm the client and prevent further increases in intracranial pressure. The nurse can reduce stimuli by minimizing noise and light in the client's environment and limiting the number of visitors.

Administering opioids, applying restraints, and blackening the room are not appropriate nursing actions for this situation. Administering opioids can cause respiratory depression and is not recommended for clients with increased intracranial pressure. Applying restraints can increase agitation and is not recommended for clients who are restless. Blackening the room can disorient the client and is not recommended.

A. Peripheral edema B. Diarrhea C. Decreased pedal pulses D. Hypertension

Correct Answer is D

Explanation

A nurse collecting data from a client who is 6 days post craniotomy for removal of an intracerebral aneurysm should monitor the client for hypertension as a manifestation of increased intracranial pressure. Increased intracranial pressure can cause changes in blood pressure, including hypertension.

Peripheral edema is not a manifestation of increased intracranial pressure. Peripheral edema is swelling in the extremities and can be caused by a variety of conditions.

Diarrhea is not a manifestation of increased intracranial pressure. Diarrhea is loose or watery stools and can be caused by a variety of conditions.

Decreased pedal pulses are not a manifestation of increased intracranial pressure. Decreased pedal pulses can indicate poor circulation to the feet and can be caused by a variety of conditions.

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A nurse is completing a neurovascular check for a client who had an open reduction internal fixation surgery. Which of the following findings should the nurse identify as possible manifestations of compartment syndrome? (Select all that apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting in the planning of preventative care for a client who is restless following a traumatic brain injury with increased intracranial pressure. Which of the following is an appropriate nursing action?

Correct Answer is C

Explanation

A nurse is collecting data from a client who is 6 days post craniotomy for removal of an intracerebral aneurysm. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure?

Correct Answer is D

Explanation

A nurse is discussing skeletal and skin traction with a newly licensed nurse. Which of the following statements should the nurse identify as an indication that the newly licensed nurse understands these therapies?

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A nurse is collecting data from a client following the application of a leg cast for the treatment of a fracture. Which of the following findings should the nurse expect to find first if the cast is too tight?

A nurse is completing a neurovascular check for a client who had an open reduction internal fixation surgery. Which of the following findings should the nurse identify as possible manifestations of compartment syndrome? (Select all that apply)

A nurse is planning care for several clients and is considering the clients' risk for stroke. Which of the following conditions places the client at risk for an ischemic embolic stroke?