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 B

Explanation

If a client reports skin irritation around the upper edge of a lower-leg cast, the nurse should petal the edges of the cast. This involves applying adhesive strips or moleskin around the edges of the cast to smooth them out and prevent them from rubbing against the skin.

a. Suggesting that the client use a blunt object such as a comb to relieve the itch is not recommended as it can cause further irritation or damage to the skin.

c. Telling the client to apply lotion to the irritated skin is not recommended as it can cause further irritation or damage to the skin and may also damage the cast.

d. Bivalving the cast is not necessary for skin irritation around the upper edge of the cast. Bivalving involves cutting the cast in half to relieve pressure and is typically only done in cases of severe swelling or compartment syndrome.

A. A client who has an arteriovenous malformation B. A client who has thrombocytopenia C. A client who has chronic atrial fibrillation D. A client who has uncontrolled hypertension

Correct Answer is C

Explanation

A client who has chronic atrial fibrillation is at risk for an ischemic embolic stroke. An ischemic embolic stroke occurs when a blood clot that forms in one part of the body travels to the brain and blocks blood ﬂow². Atrial fibrillation is a type of irregular heart rhythm that can cause blood to pool, thicken, and clot in the heart or arteries near it³. Pieces of these clots can travel to the brain and cause an ischemic embolic stroke³.

A client who has an arteriovenous malformation is not at risk for an ischemic embolic stroke.

A client who has thrombocytopenia is not at risk for an ischemic embolic stroke.

A client who has uncontrolled hypertension is at risk for a stroke but not specifically an ischemic embolic stroke.

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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 client who has a lower-leg cast reports skin irritation around the upper edge of the cast. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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?

Correct Answer is C

Explanation

A nurse is receiving a transfer report for a client who has a head injury. The client has a Glasgow Coma Scale (GCS) score of 3 for eye-opening, 5 for best verbal response, and 5 for best motor response. Which of the following is an appropriate conclusion based on this data?

A nurse is collecting data from a client who has an exacerbation of gout. Which of the following findings should the nurse expect? (Select all that apply.)

A nurse is assisting with the plan of care for an older adult client who is 4 hr postoperative following an open reduction and internal fixation of a fractured femur. Which of the following interventions should the nurse include in the plan of care?

A nurse is reinforcing teaching with a client who has a knee injury. When describing range-of-motion exercises, the nurse should explain that the knee is which of the following types of joints?

While collecting data from a client who has a cast on his right leg, a nurse locates an area on the cast that feels warm to the touch. Which of the following findings should the nurse identify as a complication to the client's condition?

A nurse in an urgent care center is caring for a client who fell and injured her ankle. The ankle appears swollen and ecchymotic. Which of the following interventions should the nurse take? (Select all that apply)

A nurse is assisting with caring for a client who has a new concussion following a motor-vehicle crash. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure?

A nurse is caring for a client who is difficult to arouse and very sleepy for several hours following a generalized tonic-clonic seizure. Which of the following descriptions should the nurse use when documenting this finding in the medical record?