The nurse is caring for a client who develops compartment syndrome from a severely fractured arm. The client asks the nurse why this can happen. What is the best response by the nurse?
A bone fragment has injured the nerve supply in the area.
An injured artery causes impaired arterial perfusion through the compartment.
Bleeding and swelling cause increased pressure in an area that cannot expand.
The fascia expands with injury, causing pressure on underlying nerves and muscles.
The Correct Answer is C
Choice A reason: A bone fragment has injured the nerve supply in the area is not the best response by the nurse. This may be a possible complication of a fracture, but it does not explain the mechanism of compartment syndrome. Compartment syndrome is a condition where the pressure within a closed space (such as a muscle compartment) exceeds the perfusion pressure and causes ischemia and necrosis of the tissues. A bone fragment may damage the nerve, but it does not cause increased pressure in the compartment.
Choice B reason: An injured artery causes impaired arterial perfusion through the compartment is not the best response by the nurse. This may be a possible cause of compartment syndrome, but it is not the most common one. Compartment syndrome is more often caused by venous obstruction than arterial obstruction. An injured artery may reduce the blood flow to the compartment, but it does not cause increased pressure in the compartment.
Choice C reason: Bleeding and swelling cause increased pressure in an area that cannot expand is the best response by the nurse. This is the most common cause of compartment syndrome and explains the pathophysiology of the condition. Bleeding and swelling are the result of inflammation and tissue injury that occur after a fracture. They increase the volume of fluid in the compartment, which cannot expand due to the rigid fascia that surrounds it. This leads to increased pressure in the compartment, which compresses the blood vessels, nerves, and muscles and causes ischemia and necrosis of the tissues.
Choice D reason: The fascia expands with injury, causing pressure on underlying nerves and muscles is not the best response by the nurse. This is not a correct statement, as the fascia does not expand with injury. The fascia is a tough connective tissue that encloses the muscle compartments and limits their expansion. The fascia is part of the problem, not the cause, of compartment syndrome. The fascia prevents the compartment from accommodating the increased volume of fluid and causes increased pressure in the compartment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Alcohol can trigger a gout attack because it increases the production and decreases the excretion of uric acid, which is the substance that causes inflammation and pain in the joints. Alcohol also dehydrates the body, which can worsen the symptoms of gout.
Choice B reason: Fruit juice is not a beverage that can trigger a gout attack. Fruit juice contains natural sugars and antioxidants, which may have a beneficial effect on the uric acid levels and the inflammation in the body. However, fruit juice should be consumed in moderation, as excess sugar intake can lead to weight gain and other health problems.
Choice C reason: Milk is not a beverage that can trigger a gout attack. Milk contains protein and calcium, which may help lower the uric acid levels and the risk of gout. Milk also has antiinflammatory properties, which may reduce the pain and swelling in the joints.
Choice D reason: Coffee is not a beverage that can trigger a gout attack. Coffee contains caffeine and antioxidants, which may have a protective effect on the uric acid levels and the inflammation in the body. Coffee also has a diuretic effect, which may help flush out the excess uric acid from the kidneys.
Correct Answer is A
Explanation
Choice A reason: This is the highest priority client because sudden and increasing pain in a fractured arm can indicate a complication, such as compartment syndrome, infection, or nerve damage. Compartment syndrome is a condition where the pressure inside the muscles increases to dangerous levels, causing severe pain, reduced blood flow, and tissue death. Infection is a condition where microorganisms invade the wound site, causing inflammation, pus, and fever. Nerve damage is a condition where the nerves are injured by the fracture, causing numbness, tingling, or weakness. The nurse should see this client first and assess the arm for any signs of these complications, such as swelling, pallor, loss of sensation, or impaired movement. The nurse should also elevate the arm, loosen any bandages or casts, and administer pain medication as ordered.
Choice B reason: This is not the highest priority client because a fractured ankle is a common and stable condition that affects the lower extremity. A glass of water is a comfort and hydration need that can be met by the nurse or another staff member. The nurse should see this client after the more urgent clients and provide the glass of water, as well as monitor the ankle for any signs of complications, such as edema, infection, or impaired circulation.
Choice C reason: This is not the highest priority client because rheumatoid arthritis is a chronic and manageable condition that affects the joints. A scheduled pain medication is a routine and preventive need that can be met by the nurse or another staff member. The nurse should see this client after the more urgent clients and administer the pain medication, as well as assess the joints for any signs of inflammation, stiffness, or deformity.
Choice D reason: This is not the highest priority client because a discharge teaching is a discharge and education need that can be met by the nurse or another staff member. The nurse should see this client last and teach the client how to use the crutches, as well as provide any other discharge instructions, such as wound care, activity restrictions, or followup appointments.
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