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. "Our child has a better grasp of reality." B. "Our child is able to complete his homework on time." C. "Our child has lost some weight since his last appointment." D. "Our child has increased his daily caloric intake."

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.

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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

Naxlex Comprehensive Predictor Exams

A nurse is verifying informed consent for a client who is preoperative for a vaginal hysterectomy. Which of the following statements should the nurse identify as an indication that the client has given informed consent?

Correct Answer is A

Explanation

A nurse is reinforcing teaching with the parents of a child who has ADHD and is taking methylphenidate. Which of the following statements by the parents indicates that the medication is effective?

Correct Answer is B

Explanation

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