In assessing a client with ulcers on the lower extremity, which findings indicate that the ulcers are likely to be of venous, rather than arterial, origin?

1. The client is most likely experiencing compartment syndrome, which is a condition where increased pressure within a closed space compromises blood flow and tissue perfusion. Compartment syndrome can occur after a fracture, especially if a cast or splint is applied too tightly. Some of the signs and symptoms of compartment syndrome are severe pain, paresthesia, pallor, and pulselessness.
2. Two actions the nurse should take to address compartment syndrome are:
   • Elevate the extremity above the level of the heart to reduce swelling and improve venous return.
   • Remove the cast or loosen the dressing to relieve the pressure and restore blood flow. This may require notifying the physician or obtaining an order for bivalving or cutting the cast.
3. Two parameters the nurse should monitor to assess the client’s condition are:
   • Capillary refill of the affected fingers, which should be less than 3 seconds. A prolonged capillary refill indicates poor perfusion and tissue ischemia.
   • Blood pressure of the client, which should be maintained within normal limits. Hypotension can worsen the perfusion deficit and lead to tissue necrosis.

Choice A reason: Presenting a calm, supportive demeanor is an appropriate intervention for a client who is experiencing anxiety and hallucinations. The nurse should use a soothing tone of voice, maintain eye contact, and avoid arguing or challenging the client's perceptions. This can help reduce the client's agitation and promote trust.

Choice B reason: Reorienting to day and time frequently is an appropriate intervention for a client who is experiencing anxiety and hallucinations. The nurse should provide reality-based information and reminders about the client's situation, such as the reason for hospitalization, the name of the nurse, and the expected plan of care. This can help the client regain a sense of orientation and control.

Choice C reason: Administering an as needed (PRN) dose of lorazepam is an appropriate intervention for a client who is experiencing anxiety and hallucinations. Lorazepam is a benzodiazepine that can reduce anxiety, agitation, and psychotic symptoms by enhancing the effects of gamma-aminobutyric acid (GABA), an inhibitory neurotransmitter in the brain. The nurse should monitor the client's vital signs, level of sedation, and risk of falls after giving the medication.

Choice D reason: Turning the television on for distraction is not an appropriate intervention for a client who is experiencing anxiety and hallucinations. The television can increase the sensory stimulation and confusion for the client, and may worsen the hallucinations or delusions. The nurse should provide a quiet and safe environment for the client.

Choice E reason: Applying soft wrist restraints bilaterally is not an appropriate intervention for a client who is experiencing anxiety and hallucinations. Restraints can increase the anxiety and agitation for the client, and may cause physical or psychological harm. The nurse should use restraints only as a last resort when other less restrictive measures have failed to protect the client or others from harm.