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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Related Questions
Correct Answer is D
Explanation
A. "It is my responsibility to obtain informed consent from the client prior to the procedure." is incorrect. It is the provider's responsibility to explain the procedure, its risks, benefits, and alternatives to the client, not the nurse's. The nurse's role is to witness the signing of the consent form.
B. "I will sign the consent form to indicate that the client has received written materials explaining the procedure." is incorrect. The nurse's role is to witness the client's signature, but the nurse does not sign to indicate that the client has received written materials.
C. "I will provide the client with an explanation of the procedure before I sign the consent form." is incorrect. The nurse should not provide the explanation of the procedure; this is the responsibility of the provider. The nurse ensures that the client understands and is signing voluntarily.
D. "When I sign the consent form, I am stating that the client appears to be competent to give consent." is correct. The nurse’s role is to witness the signing of the consent form and ensure that the client appears to be competent to provide consent. The nurse does not provide the explanation but confirms that the client is signing voluntarily and understands the procedure.
Correct Answer is B
Explanation
A. "I can take antacids at the same time as this medication.": This is incorrect. Pantoprazole is a proton pump inhibitor (PPI), and taking antacids at the same time can interfere with the medication's effectiveness. It is generally recommended to space out antacids and PPIs by at least 1 hour.
B. "I have to take this medication on an empty stomach.": This is correct. Pantoprazole should be taken on an empty stomach, typically 30 minutes before breakfast, to optimize absorption and effectiveness.
C. "I should expect to have diarrhea while taking this medication.": Diarrhea is not a common side effect of pantoprazole. While side effects such as headache, nausea, and abdominal pain are more common, diarrhea is not typically expected.
D. "I will need to remain upright for 1 hour after taking the medication.": This is incorrect. While it is generally advised to remain upright for a period after taking medications like bisphosphonates, it is not required for pantoprazole. The main instruction for pantoprazole is to take it on an empty stomach before eating.
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