A nurse is monitoring a client's lower extremity following the placement of a cast earlier in the day. Which of the following findings should the nurse identify as manifestations of compartment syndrome? (Select all that apply.)
Pale-colored toes
Decreased skin turgor
Pain relieved by analgesia
Diminished capillary refill
Sensation of tingling
Correct Answer : A,D,E
A. Pale-colored toes are a sign of compromised circulation, which is a key manifestation of compartment syndrome. Decreased blood flow to the affected limb can cause pallor, which requires immediate intervention to prevent permanent damage.
B. Decreased skin turgor is incorrect. Skin turgor is an indicator of hydration status and is not directly related to compartment syndrome.
C. Pain relieved by analgesia is incorrect. One of the hallmark signs of compartment syndrome is severe pain that is not relieved by analgesia and worsens with passive movement.
D. Diminished capillary refill is correct. Delayed capillary refill (longer than 2 seconds) suggests poor perfusion, which can indicate increased pressure within the compartment.
E. Sensation of tingling is correct. Paresthesia (tingling or numbness) is an early sign of nerve compression due to swelling within the compartment. If untreated, this can progress to permanent nerve and muscle damage.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "Our child has a better grasp of reality.": This is not the primary goal of methylphenidate. While it may help with focus and attention, the medication's goal is to improve concentration and reduce hyperactive behaviors in children with ADHD, not directly influence their grasp of reality.
B. "Our child is able to complete his homework on time.": This is correct. Methylphenidate, a stimulant used to treat ADHD, helps improve attention, focus, and impulse control. A child who can complete homework on time demonstrates improved attention and task completion, which is the desired outcome.
C. "Our child has lost some weight since his last appointment.": While weight loss can be a side effect of methylphenidate, it is not an indicator that the medication is effective. The goal is to manage ADHD symptoms, not necessarily to cause weight loss.
D. "Our child has increased his daily caloric intake.": This is incorrect. A common side effect of methylphenidate is decreased appetite, so an increase in caloric intake would not be expected.
Correct Answer is D
Explanation
A. Positive clonus is a sign of hyperreflexia and can indicate worsening preeclampsia or severe central nervous system irritability. It is not a therapeutic effect of magnesium sulfate.
B. Urinary output 20 mL/hr is below the minimum expected urine output (which is generally 30 mL/hr). This finding suggests oliguria and may be a sign of worsening renal function, which is not a therapeutic effect of magnesium sulfate.
C. Respiratory rate 10/min is too low. Magnesium sulfate can cause respiratory depression, and a respiratory rate of 10/min may indicate toxicity. This is not a therapeutic effect.
D. Deep tendon reflexes 2+ is the correct answer. Magnesium sulfate is used to prevent seizures in preeclampsia by acting as a CNS depressant. A normal response of 2+ for deep tendon reflexes indicates that magnesium sulfate is having a therapeutic effect and the client is not experiencing magnesium toxicity (which would typically cause a decreased reflex response..
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