A client who has developed acute compartment syndrome from a compound fracture of the arm asks the nurse to define what this means. Based on an understanding of the condition, the nurse should explain that:
Bleeding and swelling cause increased pressure under the fascia.
Displaced bones compress nerves and vessels.
Blood supply to the bone is interrupted.
Compression of the muscle tissue restricts blood flow to the area.
The Correct Answer is A
Choice A Reason
Acute compartment syndrome occurs when bleeding or swelling within an enclosed bundle of muscles – known as a muscle compartment – leads to increased pressure. This pressure can impede blood flow to the body tissue and destroy function. The fascia, which is a tough layer of fibrous tissue, does not stretch easily, so any swelling or bleeding can quickly lead to increased pressure.
Choice B Reason
While displaced bones can compress nerves and vessels, this is not the primary mechanism of acute compartment syndrome. Displaced bones are more likely to cause direct injury or impingement, but compartment syndrome specifically refers to the pressure build-up within a muscle compartment that affects circulation and tissue viability.
Choice C Reason
Interruption of blood supply to the bone is a serious concern and can lead to conditions such as avascular necrosis. However, in the context of acute compartment syndrome, the primary issue is the pressure within the muscle compartment rather than direct disruption of blood supply to the bone.
Choice D Reason
Compression of muscle tissue can restrict blood flow to the area, which is a part of the pathophysiology of compartment syndrome. However, the compression is a result of increased pressure within the compartment, not the primary cause. The increased pressure is due to bleeding and swelling, which is why choice A is the most accurate description.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason
Petechiae on the chest are a classic sign of fat emboli syndrome (FES). FES is a rare but serious complication that can occur after a long bone fracture, such as a femur fracture. The petechiae result from small fat droplets that travel to the skin's capillaries and cause pinpoint hemorrhages. This symptom is part of the classic triad for FES, which includes respiratory distress, neurological symptoms, and a petechial rash.
Choice B Reason
While an edematous calf may be a concern for deep vein thrombosis or other complications following a fracture, it is not a specific indicator of FES. Edema in the calf could be due to various reasons, including local trauma from the fracture itself or immobilization.
Choice C Reason
An elevated temperature can be associated with many post-injury complications, including infection or inflammatory response. However, it is not specific to FES. While patients with FES may present with fever, it is not one of the primary diagnostic criteria.
Choice D Reason
Paresthesia distal to the fracture could indicate nerve damage or compartment syndrome, which are important to assess in a patient with a femur fracture. However, paresthesia is not a specific sign of FES. The neurological symptoms associated with FES are more generalized and often include confusion or altered mental status.
Correct Answer is B
Explanation
Choice A reason:
Performing a 12-lead electrocardiogram and calling a rapid response team are important steps when a pulmonary embolism is suspected. However, these actions are not the immediate first-line interventions. The priority is to address the client's oxygenation needs to prevent further hypoxemia and potential cardiac arrest.
Choice B reason:
Elevating the head of the bed and applying 2 liters of nasal oxygen is the most appropriate initial intervention. This position helps improve the expansion of the lungs and oxygenation, while the supplemental oxygen can help alleviate hypoxemia, which is critical in the management of a pulmonary embolism.
Choice C reason:
While ensuring the client remains calm is beneficial, administering lorazepam is not the first-line treatment for a suspected pulmonary embolism. Lorazepam may be used for its anxiolytic effects, but it does not address the immediate life-threatening issues of oxygenation and potential hemodynamic instability.
Choice D reason:
Increasing the intravenous rate may be considered to maintain adequate hydration and venous return, but it is not the first intervention for a suspected pulmonary embolism. The priority is to stabilize the client's respiratory status and oxygenation.
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