The nurse is caring for a client who has a fractured tibia and is in a cast. Which of the following findings is a manifestation of compartment syndrome?
Redness and warmth of affected extremity
Slow capillary refill
Reduced level of consciousness
Pain and bleeding
The Correct Answer is B
Choice A Reason: Redness and warmth of affected extremity are not signs of compartment syndrome, but they may indicate other conditions such as infection or inflammation.
Choice B Reason: Slow capillary refill is a sign of compartment syndrome, as it indicates that there is impaired blood flow to the tissues due to increased pressure within the fascial compartment.
Choice C Reason: Reduced level of consciousness is not a sign of compartment syndrome, but it may indicate other serious conditions such as head injury, stroke, or hypoxia.
Choice D Reason: Pain and bleeding are not specific signs of compartment syndrome, but they may occur due to the fracture or other causes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason: Buffalo hump and moon face are physical assessment findings that the nurse would expect to observe in a client with Cushing's syndrome, as they indicate fat redistribution and accumulation due to excess cortisol production.
Choice B Reason: Dry, scaly skin and cold intolerance are not physical assessment findings that the nurse would expect to observe in a client with Cushing's syndrome, but they may indicate hypothyroidism, which affects the metabolism and skin condition.
Choice C Reason: Dry, sticky mucous membranes and hypovolemia are not physical assessment findings that the nurse would expect to observe in a client with Cushing's syndrome, but they may indicate dehydration or diabetes insipidus, which affect the fluid balance and urine output.
Choice D Reason: Exophthalmos and tachycardia are not physical assessment findings that the nurse would expect to observe in a client with Cushing's syndrome, but they may indicate hyperthyroidism, which affects the eye protrusion and heart rate.
Correct Answer is D
Explanation
Choice A Reason: Telling the client that this is to be expected after surgery is not the first action that the nurse should take, as it may indicate a complication such as increased intraocular pressure, hemorrhage, or infection.
Choice B Reason: Placing the client in a supine position is not the first action that the nurse should take, as it may worsen the pain and increase intraocular pressure.
Choice C Reason: Documenting the findings is not the first action that the nurse should take, as it may delay the intervention and outcome.
Choice D Reason: Notifying the surgeon is the first action that the nurse should take, as it indicates that the client needs immediate evaluation and treatment to prevent vision loss or permanent damage to the eye.
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