A client is reporting pain in her casted leg and the nurse notes some swelling distal to the cast. The nurse has administered analgesics and elevated the limb. Thirty minutes after administering the analgesics, the client states the pain is unrelieved. The nurse should identify the warning signs of what complication?
Compartment syndrome
Muscle wasting
Skin breakdown
Joint Stiffness
The Correct Answer is A
A. Compartment syndrome. The client’s unrelieved pain, despite analgesics, and the presence of swelling distal to the cast are warning signs of compartment syndrome. This is a medical emergency that occurs when increased pressure within a closed muscle compartment reduces blood flow, leading to tissue damage and pain.
B. Muscle wasting. Muscle wasting typically occurs over time due to disuse and is not a sudden, acute complication like compartment syndrome.
C. Skin breakdown. Skin breakdown could occur from improper cast fitting or prolonged pressure, but it would not cause unrelieved pain in the same way as compartment syndrome.
D. Joint stiffness. Joint stiffness can occur in casted limbs after removal, but it is not an acute complication like compartment syndrome.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Troponin: Troponin is the most specific and reliable biomarker for myocardial injury. Levels rise within 3-6 hours and remain elevated for days, providing diagnostic and prognostic information.
B. Alkaline phosphatase: This is related to liver and bone disorders, not cardiac events.
C. Creatine kinase (CK): While CK-MB is specific to cardiac tissue, it is less specific and remains elevated for a shorter period compared to troponin.
D. Myoglobin: Myoglobin is an early but nonspecific marker of muscle damage and is not as reliable for diagnosing myocardial injury.
Correct Answer is D
Explanation
A. “There is some swelling in your right leg that is making you feel this way.” Swelling would typically cause discomfort or pressure, but it would not be responsible for the sensation of pain in the amputated limb.
B. "Your brain is responding to being inactive from the surgery." This answer does not address the real cause of the pain, which is related to the brain's continued perception of the missing limb.
C. "Don't worry about your right foot. The pain will go away within a few days." Phantom limb pain is a common phenomenon after amputation and may persist long-term. Dismissing it is not appropriate.
D. "Your brain is still receiving impulses about your right foot." This is an accurate explanation for phantom limb pain. After amputation, the brain may still interpret sensations from the absent limb, causing pain or discomfort in the "missing" foot.
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