The nurse is caring for a preschool child with a cast applied recently for a fractured tibia. Which assessment finding indicates possible compartment syndrome?
Pain responding well to prescribed dose of Morphine.
ltching unrelieved by Diphenhydramine (Benadryl administration.
Lower extremities temperature cool bilaterally.
Tingling in the toes of fractured extremity and decreased sensation.
The Correct Answer is D
Compartment syndrome is a condition characterized by increased pressure within a muscle compartment, leading to impaired blood flow and potential tissue damage. It can occur when swelling or bleeding within a confined space, such as a cast, causes increased pressure on the surrounding tissues.
Tingling in the toes and decreased sensation can be indicative of nerve compression or damage due to increased pressure in the compartment. It is important to recognize these neurological changes as potential signs of compartment syndrome.
Signs and symptoms of compartment syndrome may include:
- Severe pain that is out of proportion to the injury or not relieved by pain medication.
- Swelling and tightness in the affected area.
- Numbness or tingling.
- Pale or cool skin over the affected area.
- Weakness or decreased sensation in the affected limb.
- In severe cases, paralysis or loss of pulse in the affected area.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The glomerular filtration rate is a measure of how effectively the kidneys filter waste and excess fluid from the blood. It is a key indicator of kidney function. CKD is staged based on the GFR, which provides an estimate of the percentage of normal kidney function remaining.
While serum creatinine and urea levels are important markers used to assess kidney function, they are not the sole criteria for staging CKD. The degree of altered mental status and total daily urine output are important clinical observations but are not used for staging CKD.
Correct Answer is A
Explanation
Acute renal failure is characterized by a sudden decline in kidney function, resulting in the inability of the kidneys to adequately filter waste products and maintain fluid and electrolyte balance. Monitoring urine output is essential in assessing kidney function and determining the severity of renal failure. A decrease in urine output or anuria may indicate worsening renal function and the need for immediate interventions.
Assessing electrolyte levels, such as sodium, potassium, calcium, and phosphorus, is crucial because renal failure can disrupt the balance of these electrolytes in the body. Imbalances can lead to complications such as electrolyte abnormalities, cardiac dysrhythmias, and neuromuscular disturbances. Prompt identification and management of electrolyte imbalances are essential in preventing further complications and supporting optimal patient outcomes.
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