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 ["A","B","E"]
Explanation
Small bowel obstruction can lead to the accumulation of gastric contents above the obstruction, causing vomiting.
Obstruction of the small bowel can result in crampy, colicky abdominal pain and abdominal distention.
Electrolyte imbalances, such as hypokalemia (low potassium), can occur due to vomiting and inadequate intake in cases of small bowel obstruction.
The following finding is not directly associated with small bowel obstruction:
Pain relief after eating is more commonly associated with peptic ulcer disease, not small bowel obstruction.
While blood in the stool can be seen in some cases of bowel obstruction, it is more commonly associated with lower gastrointestinal bleeding or other conditions affecting the colon, rather than small bowel obstruction.
Correct Answer is C
Explanation
Suctioning secretions away from the suture line helps maintain the surgical site's cleanliness and promotes healing. It helps prevent accumulation of mucus or oral secretions that can interfere with the healing process and increase the risk of infection. The nurse should use a gentle suctioning technique to avoid disrupting the surgical site.
Applying Neosporin to the surgical site is not typically recommended unless specifically prescribed by the healthcare provider. It is important to follow the provider's instructions regarding wound care.
Applying elbow immobilizers when not being held is not necessary for cleft lip surgery. Elbow immobilizers are usually used in other surgical procedures or for other reasons, such as preventing contractures.
Feeding increased amounts of formula to prevent weight loss is not an appropriate intervention for the first few days after cleft lip surgery. The surgical site may be sensitive, and the child may experience difficulty with feeding initially. The nurse should provide guidance and support for feeding techniques appropriate for the child, which may include using specialized bottles or positioning techniques.
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