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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Taking ferrous sulfate on an empty stomach can increase absorption but often causes nausea and gastrointestinal upset. Clients are usually advised to take it with a small amount of food if stomach upset occurs.
B. Drinking more milk does not prevent constipation and can actually decrease the absorption of iron due to calcium content. Adequate fluids and fiber are recommended instead to manage constipation.
C. Black stools are a common and expected side effect of ferrous sulfate due to iron content. Reporting them is not necessary unless accompanied by other concerning symptoms like bleeding or abdominal pain.
D. Mixing ferrous sulfate elixir with a full glass of water helps dilute the medication, reducing irritation to the gastrointestinal tract. It also ensures proper dosing and facilitates easier swallowing of the liquid medication.
Correct Answer is A
Explanation
A. Oral suction equipment is correct. During a seizure, there is a risk of aspiration due to the loss of airway control. Oral suction equipment should be readily available in the room to clear the airway if needed, especially if the client experiences a seizure with oral secretions.
B. Tongue depressor is incorrect. A tongue depressor should never be used during a seizure. Inserting a tongue depressor into the mouth can result in injury to both the client and the caregiver and should be avoided.
C. Tracheostomy tray is incorrect. While a tracheostomy tray might be necessary for clients with tracheostomies, it is not a standard requirement for clients on seizure precautions unless the client has specific respiratory concerns or requires a tracheostomy for airway management.
D. Wrist restraints is incorrect. Wrist restraints are not recommended during a seizure, as they can cause injury and impede movement. Instead, the goal is to provide a safe environment to prevent injury during a seizure.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.