Clinical Scenario:

A nurse is assessing a patient who had an external fixation device placed for a tibial fracture 8 hours ago. The patient reports increasing pain that is not relieved by prescribed pain medications. Upon assessment, the nurse notes swelling, a pale and cool foot, and diminished sensation in the toes.

Which of the following assessments should the nurse perform next to further evaluate for compartment syndrome?

Assess for the presence of pedal pulses and capillary refill time.

Measure the patient's calf circumference and compare it bilaterally.

Ask the patient to flex and extend the affected foot to assess for range of motion.

Check for redness and drainage at the pin sites of the external fixation device.

Answer and Explanation

The Correct Answer is A

A. Assess for the presence of pedal pulses and capillary refill time: Compartment syndrome can lead to diminished or absent pulses, delayed capillary refill, and decreased circulation. Assessing pedal pulses and capillary refill is a crucial step in confirming the diagnosis.

B. Measure the patient’s calf circumference and compare it bilaterally: Measuring limb circumference can help assess swelling, but it is not the most critical assessment in this situation. Capillary refill and pedal pulses provide more immediate information about circulation.

C. Ask the patient to flex and extend the affected foot to assess for range of motion: Limited movement can be a sign of compartment syndrome, but if severe pain is already present, further movement may cause more damage. Assessing circulation should be prioritized first.

D. Check for redness and drainage at the pin sites of the external fixation device: Redness and drainage may indicate infection, but this does not directly assess for compartment syndrome. Circulatory assessment is more urgent.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

A. Fat embolism syndrome: Fat embolism syndrome (FES) typically presents with respiratory symptoms, such as dyspnea, petechiae, and confusion. Gastrointestinal symptoms like nausea and bloating are not characteristic of FES.

B. Deep vein thrombosis (DVT): DVT primarily presents with unilateral leg swelling, pain, and warmth, rather than gastrointestinal symptoms. While immobilization increases the risk of DVT, the patient’s symptoms do not align with this condition.

C. Compartment syndrome: Compartment syndrome involves severe pain, pallor, paresthesia, pulselessness, and paralysis in an affected limb. Gastrointestinal symptoms are not associated with compartment syndrome.

D. Cast syndrome (Superior Mesenteric Artery Syndrome - SMAS): SMAS occurs when the full-body cast compresses the superior mesenteric artery, leading to nausea, bloating, abdominal pain, and weight loss due to gastric obstruction. This condition is common in patients immobilized for prolonged periods.

A. A rapidly growing, irregular brown lesion with uneven borders B. A slow-growing, pearly or waxy nodule with visible blood vessels with central ulceration C. A dark, flat lesion with a satellite pattern of spreading pigmentation D. A firm, scaly lesion with a rough, honey crusted surface

Correct Answer is B

Explanation

A. A rapidly growing, irregular brown lesion with uneven borders. This description is more characteristic of melanoma, which presents as an asymmetrical, dark lesion with irregular borders and rapid growth.

B. A slow-growing, pearly or waxy nodule with visible blood vessels with central ulceration. BCC typically appears as a pearly, waxy nodule with visible telangiectasia (small blood vessels). It grows slowly and may develop a central ulceration over time.

C. A dark, flat lesion with a satellite pattern of spreading pigmentation. This description aligns more with melanoma, which often spreads in a radial pattern with satellite lesions.

D. A firm, scaly lesion with a rough, honey-crusted surface. This description is more consistent with squamous cell carcinoma (SCC), which presents as a rough, scaly lesion that may ulcerate.

View Question and Answer

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

A nurse is performing a skin assessment on a patient and suspects basal cell carcinoma (BCC). Which of the following findings would support this suspicion?

Correct Answer is B

Explanation

A 45-year-old male patient arrives at the emergency department with partial-thickness burns on his entire right arm, the front of his right leg, and the entire front of his torso. Using the Rule of Nines, what is the estimated Total Body Surface Area (TBSA) burned?

A nurse is caring for an adolescent client who has a newly applied fiberglass cast for a fractured tibia. Which of the following is the priority action for the nurse to take?

A nurse is providing initial emergency care for a client with extensive burns. Which of the following interventions should the nurse perform first?

A nurse is providing medication education to a patient newly prescribed ethambutol for tuberculosis (TB) treatment. The nurse should instruct the patient to report which of the following side effects immediately?

A nurse is caring for a client who has a new short-leg cast on his lower leg to treat an ankle fracture. Which of the following findings requires immediate notification of the provider?

A nurse in the emergency department is caring for a client who has extensive partial and full-thickness burns of the head, neck, and chest. While planning the client's care, the nurse should identify which of the following risks as the priority for assessment and intervention?

A nurse is assessing a patient who has sustained a burn injury. The affected area is dry, white, and charred, with no pain present. Based on the classification of burns, the nurse understands this burn is: