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

Answer and Explanation

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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Correct Answer is A

Explanation

A. "I am thankful I am done having children" is correct. This statement demonstrates the client's understanding of the procedure’s purpose, which is typically done to end the ability to conceive. The client is reflecting on a key aspect of the procedure, showing an informed decision about the surgery.

B. "I should expect my periods to resume in 1 month" is incorrect. A vaginal hysterectomy typically results in the permanent cessation of periods, so this statement indicates a lack of understanding of the procedure's effects.

C. "I will have a large scar on my stomach after this procedure" is incorrect. A vaginal hysterectomy is performed through the vaginal canal, and the client typically should not have a large abdominal scar. This statement may indicate a misunderstanding of the surgery's approach.

D. "I will no longer need a regular gynecological examination" is incorrect. While a vaginal hysterectomy removes the uterus, clients still need regular gynecological examinations, including Pap smears and other assessments, depending on their individual health needs. This statement reflects a misunderstanding of ongoing care requirements.

A. Docusate B. Ibuprofen C. Aspirin D. Omeprazole

Correct Answer is A

Explanation

A. Docusate is correct. Docusate is a stool softener, and it does not have a significant effect on blood clotting. Therefore, it is considered safe for use with warfarin, which requires careful monitoring to avoid interactions that may increase bleeding risks.

B. Ibuprofen is incorrect. Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID. that can increase the risk of bleeding when used with warfarin by inhibiting platelet aggregation and affecting clotting factors.

C. Aspirin is incorrect. Aspirin also inhibits platelet function, increasing the risk of bleeding when combined with warfarin. This combination should be avoided unless specifically prescribed.

D. Omeprazole is incorrect. Although omeprazole is often used to treat gastrointestinal issues, it may interact with warfarin and affect its metabolism. This interaction can increase the risk of bleeding, and caution is recommended when using these medications together.

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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.)

Nursing Test Bank

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