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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A reason:

Assisting the client to turn by having them grasp the side rails is not recommended immediately following a laminectomy and spinal fusion. This action could place undue stress on the surgical site and potentially disrupt the healing process. Postoperative care typically involves minimizing movement of the spine to prevent complications.

Choice B reason:

Maintaining strict bedrest for 48 hours postoperatively is not a current standard of care following a laminectomy and spinal fusion. Early ambulation, as tolerated, is encouraged to promote circulation and prevent complications such as deep vein thrombosis (DVT) and pulmonary embolism (PE).

Choice C reason:

Assessing the client's pain level and administering pain medication as needed is a critical nursing intervention postoperatively. Effective pain management is essential for promoting patient comfort, facilitating early mobilization, and preventing complications. Pain assessment and management should be tailored to the individual's needs and carried out with regular monitoring.

Choice D reason:

Placing the client in the prone position is not typically advised following a laminectomy and spinal fusion, as it may put pressure on the surgical site and cause discomfort. The preferred position is usually on the back or occasionally on the side with proper support, depending on the surgeon's protocol and the client's comfort.

A. Make sure I eat three large well-balanced meals every day with snacks in between." B. Drink ten ounces of water during meals. C. Drink coffee instead of cola. D. Increase my intake of protein."

Correct Answer is D

Explanation

Choice a reason:
For individuals with Crohn's disease, eating three large meals may not be the best approach as it can overwhelm the digestive system. Smaller, more frequent meals are often recommended to ease the digestion process and better manage symptoms.

Choice b reason:
Drinking water during meals can help with digestion, but there is no specific requirement to limit it to ten ounces. Adequate hydration is important, but the amount should be tailored to individual needs and tolerances.

Choice c reason:
Choosing coffee over cola is not necessarily beneficial for Crohn's disease management. Both beverages can potentially irritate the gastrointestinal tract, and individuals with Crohn's disease are often advised to limit caffeine and carbonated drinks.

Choice d reason:
Increasing protein intake can be beneficial for clients with Crohn's disease, especially if they have experienced weight loss or malnutrition due to their condition. Protein is essential for healing and repair of tissues, and maintaining adequate protein levels is important for overall health.

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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:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has arrived in the postoperative unit following a laminectomy and spinal fusion. Which action should the nurse take?

Correct Answer is C

Explanation

A nurse is teaching a client who is diagnosed with Crohn's disease. Which statement made by the client indicates an understanding of the teaching? "I will:

Correct Answer is D

Explanation

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