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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The nurse should identify infection as a complication to the client's condition. A warm area on the cast could indicate the presence of an underlying infection. The warmth could be due to an increase in blood flow to the area as the body tries to fight off the infection.
Uneven cast drying, pressure from the cast, and poor circulation are not complications that would cause a warm area on the cast. Uneven cast drying could cause discomfort but would not result in warmth. Pressure from the cast could cause skin breakdown but would not result in warmth. Poor circulation could cause coolness or pallor but would not result in warmth.
Correct Answer is C
Explanation
Decorticate posturing is a specific type of involuntary abnormal posturing of a person that is a sign of severe damage to the brain¹. In decorticate posture, the arms are bent to hold the hands on the chest and the fists are clenched¹. The hands may each twist inward at the wrists with knuckles facing or touching each other. This is known as the pronation of the hands.
Extension of the extremities is not a characteristic of decorticate posturing. Extension of the extremities is more characteristic of decerebrate posturing, where arms and legs are straight and rigid¹.
External rotation of the lower extremities is not a characteristic of decorticate posturing. In decorticate posture, legs are held out straight¹.
Plantar flexion of the legs is not a characteristic of decorticate posturing. In decorticate posture, legs are held out straight¹.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.