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 C
Explanation
A. Doxazosin .5 mg PO at bedtime is incorrect. The dose should be written as "0.5 mg" to include the leading zero, following proper medication administration guidelines.
B. Lorazepam 0.5 mg PO PRN at bedtime is incorrect. "PRN" should include a specific indication (e.g., anxiety, insomnia. for when it is to be administered.
C. Heparin 5000 U subcutaneous every 8 hr is correct. The prescription is clear and includes the correct dose, route, and frequency of administration.
D. MgSO4 10 g PO daily is incorrect. Magnesium sulfate is typically administered intravenously, not orally, unless specified otherwise for specific conditions, and the dosage is quite high for oral administration.
Correct Answer is C
Explanation
A. The client's heart rate has increased to 110/min is incorrect. While an increased heart rate can indicate pain, it can also be caused by other factors such as anxiety, dehydration, or fever. Heart rate alone is not the most specific or reliable indicator for the need for analgesia.
B. The client grimaces when changing positions is a possible sign of discomfort, but the level of pain cannot be accurately assessed from facial expressions alone. This may suggest mild to moderate pain but does not provide a clear numerical indication of the client's pain level.
C. The client reports pain as 7 on a scale of 0 to 10 is correct. The pain scale is a more direct and reliable measure of the client's pain experience. A rating of 7 indicates moderate to severe pain, which justifies the need for analgesic intervention.
D. The client demonstrates a decreased attention span could be related to pain or discomfort, but it may also result from other causes, such as fatigue, emotional stress, or medication side effects. This is not as definitive as a self-reported pain level.
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