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.
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Related Questions
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.
Correct Answer is A
Explanation
If a nurse is caring for a client who has a spinal cord injury and suspects that the client has autonomic dysreflexia, the first action the nurse should take is to raise the head of the bed. This can help to lower the client's blood pressure and reduce the risk of complications such as stroke.
Checking the client for a fecal impaction is an important step in identifying and treating the underlying cause of autonomic dysreflexia, but it is not the first action the nurse should take.
Checking the client's bladder for distention is an important step in identifying and treating the underlying cause of autonomic dysreflexia, but it is not the first action the nurse should take.
Ensuring that the room temperature is warm is not a priority intervention for a client who has autonomic dysreflexia.
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