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 ["B","C","E"]
Explanation
Choice A reason: Include many fresh fruits and vegetables in your diet is not a correct answer, because it may increase the risk of infection for the client with AIDS. Fresh fruits and vegetables may contain bacteria, parasites, or pesticides that can cause gastrointestinal or systemic infections in immunocompromised clients. The nurse should advise the client to wash, peel, or cook fruits and vegetables before eating them, or to avoid them altogether if they have diarrhea or low white blood cell counts.
Choice B reason: Drink at least 2 to 3 L of fluids per day is a correct answer, because it helps prevent dehydration, maintain electrolyte balance, and flush out toxins and waste products. Fluid intake is especially important for clients with AIDS who may experience fever, sweating, vomiting, diarrhea, or oral lesions that can cause fluid loss.
Choice C reason: Eat highcalorie foods is a correct answer, because it helps prevent weight loss, muscle wasting, and malnutrition. Clients with AIDS may have increased caloric needs due to increased metabolic rate, infection, inflammation, or medication side effects. Highcalorie foods can provide energy and support immune function.
Choice D reason: Lower your caloric intake is not a correct answer, because it can worsen the nutritional status and health outcomes of the client with AIDS. Lowering caloric intake can lead to weight loss, muscle wasting, malnutrition, and increased susceptibility to infections and complications. The nurse should encourage the client to meet or exceed their caloric needs based on their weight, activity level, and disease stage.
Choice E reason: Choose foods high in protein is a correct answer, because it helps maintain muscle mass, tissue repair, and immune function. Clients with AIDS may have increased protein needs due to increased protein breakdown, infection, inflammation, or medication side effects. Highprotein foods can provide amino acids and antibodies that are essential for immune response.
Correct Answer is ["A","B","C"]
Explanation
Choice A reason: Cleansing the skin routinely after soiling occurs is an effective intervention to prevent skin injury. This is because soiling from urine, feces, sweat, or wound drainage can irritate the skin and cause inflammation, infection, or breakdown. The nurse should use a gentle cleanser and warm water and pat the skin dry. The nurse should also avoid using harsh chemicals, alcohol, or perfumes on the skin.
Choice B reason: Applying moisturizer to dry areas of skin is an effective intervention to prevent skin injury. This is because dry skin is more prone to cracking, peeling, or tearing. The nurse should use a hypoallergenic moisturizer and apply it to the skin after cleansing and drying. The nurse should also avoid using products that contain alcohol, fragrances, or dyes on the skin.
Choice C reason: Using a Hoyer lift for all transfers is an effective intervention to prevent skin injury. This is because a Hoyer lift is a mechanical device that helps to lift and move the client safely and comfortably. It reduces the friction and shear on the skin by lifting the client off the bed surface and avoiding any sliding or dragging. It also prevents the nurse from injuring themselves by lifting the client manually.
Choice D reason: Massaging the client’s reddened shoulders and heels is not an effective intervention to prevent skin injury. In fact, this may worsen the skin injury by increasing the pressure and damage to the tissues. The nurse should avoid massaging any areas that are reddened, swollen, or blistered, as these are signs of pressure ulcers. The nurse should instead relieve the pressure by repositioning the client or using pressurerelieving devices, such as pillows, foam pads, or air mattresses.
Choice E reason: Repositioning the client once per shift is not an effective intervention to prevent skin injury. This is because repositioning the client once per shift is not frequent enough to prevent the development of pressure ulcers. Pressure ulcers are caused by prolonged pressure on the skin that reduces the blood flow and oxygen to the tissues. The nurse should reposition the client at least every 2 hours or more often if needed, depending on the client's condition and risk factors.
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