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

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. “Brain death has occurred if there is no spontaneous breathing or brainstem reflexes.” Brain death is defined as the irreversible cessation of all functions of the entire brain, including the brainstem. The absence of spontaneous breathing and brainstem reflexes (such as pupillary response, gag reflex, and eye movements) are critical criteria used to confirm brain death.

B. “If respiratory efforts cease and no apical pulse is audible, brain death is present.” While the cessation of respiratory efforts is a key component of brain death, the presence or absence of an apical pulse alone is not sufficient for determining brain death. Brain death is determined based on the complete absence of brain function, including brainstem reflexes.

C. “Brain death has occurred if a person has flaccid muscles and does not awaken.” Muscle flaccidity and lack of consciousness may be signs of severe brain injury, but they do not necessarily confirm brain death. Brain death is diagnosed based on the absence of brainstem reflexes and spontaneous breathing.

D. “CPR does not restore a heartbeat, the brain cannot function.” While it is true that CPR may not restore circulation in brain-dead patients, this statement is incomplete and not a precise definition of brain death. Brain death is determined by the irreversible cessation of all brain activity, not just by the failure of CPR to restore circulation.

A. Deficits in the right visual field B. Motor retardation C. Poor impulse control D. Unable to discriminate words and letters

Correct Answer is C

Explanation

A. Deficits in the right visual field: This would be associated with a left-sided stroke, as the right hemisphere controls the left visual field.

B. Motor retardation: This is not a specific sign of right hemisphere stroke. It might be seen with other types of strokes.

C. Poor impulse control: A right hemisphere stroke may cause behavioral changes, including impulsivity, poor judgment, and difficulty in regulating emotions.

D. Unable to discriminate words and letters: This would suggest aphasia, which is typically associated with left hemisphere damage, as the left hemisphere controls language.

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Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

A nurse is caring for a client who had a stroke involving the right cerebral hemisphere. The nurse should monitor the client for which finding?

Correct Answer is C

Explanation

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