A nurse is training a newly licensed nurse. The newly licensed nurse asks if she can delegate the task of weighing several clients to an assistive personnel (AP). Which of the following responses should the nurse make?

Rationale for Correct Choices:

• Compartment syndrome: Occurs when pressure within a closed muscle compartment compromises circulation and tissue function. The client presents with classic signs: pain out of proportion, pallor (cool foot), pulselessness (non-palpable pulses), paresthesia (numbness), and paralysis (inability to move foot/toes) which are hallmark signs of compromised perfusion.

• Osteomyelitis: The presence of drainage from the splint site, increasing temperature, and markedly elevated WBC count (from 14,000 to 28,000/mm³) strongly suggest developing bone infection. The client’s open fracture and internal fixation increase susceptibility, especially with new signs of systemic infection and localized inflammation at the injury site.

Rationale for Incorrect Choices:

• Deep vein thrombosis (DVT): While trauma and immobility increase DVT risk, there is no evidence of unilateral leg swelling, calf tenderness, or redness. The primary concern here is neurovascular compromise, not venous thromboembolism, and the symptoms point more urgently to compartment syndrome and infection.

• Fat embolism syndrome: Fat embolism is a risk with long bone fractures, typically presenting within 24–72 hours with respiratory distress, hypoxia, confusion, and a petechial rash. This client is alert and not in respiratory distress, with normal oxygen saturations and no mental status changes, making fat embolism less likely at this stage.

• Pressured speech is a hallmark of mania, reflecting heightened psychomotor activity and accelerated thought processes. It often overwhelms conversation partners and makes logical communication difficult. This symptom reflects the individual’s racing mind and inability to filter or regulate their verbal output, often seen in manic episodes.
• Disorganized thought process is seen in both psychosis and mania, but manifests differently in each. In psychosis, it is often due to a breakdown in logical thinking or connection to reality. In mania, it reflects flight of ideas, rapid topic shifting, and distractibility. The presence of both symptoms indicates overlapping features.
• Excessive spending habits are consistent with manic behavior, often driven by grandiosity and poor judgment. Clients in a manic state may feel invincible or overly generous, leading them to make irrational financial decisions. These behaviors can result in significant personal or financial consequences, including debt or loss of savings.
• Hallucinations are perceptual disturbances where individuals see, hear, or feel things that are not present, primarily associated with psychosis. Auditory hallucinations, like hearing voices or unseen persons, are especially common. This indicates a loss of reality testing, which is central to diagnosing psychotic disorders.
• Lack of sleep without fatigue or distress is a key feature of mania, often preceding or accompanying a manic episode. Unlike insomnia in depression or anxiety, clients with mania may report feeling energetic and productive. The sleep deficit contributes to cognitive and emotional instability seen in manic phases.