A patient with a long leg cast reports pain in the toes. The nurse discovers that the toes are pale and cool to the touch with intact pulses and minimal neuropathy. The findings indicate that the patient may be experiencing which complications?

A fat embolism

Osteomyelitis

Compartment syndrome

A pressure ulcer

Answer and Explanation

The Correct Answer is C

A. A fat embolism typically presents with respiratory distress, altered mental status, and petechial rash, not the symptoms of pale and cool toes with intact pulses. It is unlikely to cause localized pain in the toes alone.
B. Osteomyelitis is an infection of the bone and would not cause the pale, cool appearance of the toes in this scenario. Symptoms of osteomyelitis include fever, localized pain, and swelling, but it does not present with the same vascular and neurovascular changes as compartment syndrome.
C. Compartment syndrome occurs when there is increased pressure within a muscle compartment, leading to reduced blood flow. The symptoms of pale, cool toes with pain and intact pulses are indicative of impaired circulation due to increased pressure, which is a hallmark of compartment syndrome. This is a medical emergency that requires prompt intervention.
D. A pressure ulcer typically presents with localized skin damage due to prolonged pressure, but it would not cause pale, cool toes or pain in the way compartment syndrome would.

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Correct Answer is C

Explanation

A. Auscultating heart tones can provide information about heart sounds, such as murmurs or rubs, but it is not the most effective method for diagnosing a myocardial infarction (MI).
B. Determining if the pain radiates to the left arm can help assess for MI, as pain radiating to the left arm is a common symptom of an MI. However, this alone is not sufficient to confirm the diagnosis.
C. A 12-lead ECG is the most definitive tool for diagnosing a myocardial infarction. It can detect changes in the heart's electrical activity that are characteristic of an MI, such as ST-segment elevation or depression.
D. Checking the client's blood pressure is important for overall assessment, but it is not specific for diagnosing a myocardial infarction. Blood pressure may be elevated or decreased in an MI, but it does not provide conclusive evidence of the condition.

A. Encourage use of elastic stockings. B. Monitor for shortening of the affected leg. C. Avoid flexing the hips more than 60°. D. Maintain foam wedge between legs.

Correct Answer is D

Explanation

A. Encouraging the use of elastic stockings is important for preventing deep vein thrombosis (DVT) postoperatively but does not directly prevent hip dislocation.
B. Monitoring for shortening of the affected leg is important to assess for complications such as dislocation or nerve injury, but it is not a preventive measure.
C. Avoiding flexion of the hips more than 60° is important to prevent dislocation, but the recommended limit is usually 90°, not 60°. It is crucial to keep the hip in an appropriate position to avoid excessive movement.
D. Maintaining a foam wedge between the legs is the most effective intervention to prevent hip dislocation. The wedge keeps the hips in proper alignment and prevents excessive internal rotation or adduction, which are common causes of dislocation after hip arthroplasty.

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A patient with a long leg cast reports pain in the toes. The nurse discovers that the toes are pale and cool to the touch with intact pulses and minimal neuropathy. The findings indicate that the patient may be experiencing which complications?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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