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 A
Explanation
The correct answer is choice A. The client requires total nursing care.
Choice A rationale:
A Glasgow Coma Scale (GCS) score of 8 indicates a severe head injury and significant impairment in consciousness. Clients with a GCS score of 8 or less are often unable to perform basic activities of daily living independently and require total nursing care.
Choice B rationale:
A GCS score of 8 does not indicate a deep coma. Deep coma is typically associated with a GCS score of 3-4, where the client shows minimal to no response to stimuli.
Choice C rationale:
A client who is alert and oriented would have a much higher GCS score, typically between 13 and 15. A score of 8 indicates significant impairment in consciousness, not alertness and orientation.
Choice D rationale:
A GCS score of 8 does not suggest stable neurological status. Instead, it indicates severe neurological impairment, requiring close monitoring and comprehensive care.
Correct Answer is B
Explanation
The knee is a hinge type of joint. When describing range-of-motion exercises, the nurse should explain that the knee is a hinge joint. A hinge joint is a type of synovial joint that mainly allows for flexion and extension (and a small degree of medial and lateral rotation)¹. The knee joint is formed by articulations between the patella, femur, and tibia¹.
a. The knee is not a pivot joint.
c. The knee is not a ball and socket joint.
d. The knee is not a gliding joint.
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