A nurse in an emergency department is caring for a 60-year-old client.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.
The Correct Answer is []
1. Condition: Acute Compartment Syndrome
Justification: The presence of severe pain, swelling, numbness, and a weak radial pulse along with delayed capillary refill are classic signs of acute compartment syndrome. Immediate surgical intervention (fasciotomy) is necessary to relieve the pressure within the muscle compartments.
2. Actions to Take
Prepare for Fasciotomy:
Justification: This surgical procedure will relieve the internal pressure causing the symptoms.
Request Prescription for Pain Medication:
Justification: Adequate pain management is important for client comfort and can also indicate response to treatment.
3. Parameters to Monitor
Neurovascular Status:
Justification: Monitoring for further deterioration of symptoms such as worsening numbness or weak pulses is essential.
WBC Count:
Justification: Helps in the broader assessment of possible infection, though not directly related to acute compartment syndrome
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. The client has a paralytic ileus is correct. Morphine can cause decreased gastrointestinal motility, which can exacerbate a paralytic ileus.
B. The client is experiencing a myocardial infarction is incorrect. Morphine is commonly used to manage pain and reduce myocardial oxygen demand during a myocardial infarction.
C. The client who has bronchitis pleurisy is incorrect. Morphine can be used for pain control in pleurisy, but it is not contraindicated.
D. The client who is 24 hr postoperative following hip arthroplasty is incorrect. Morphine is used for postoperative pain management.
Correct Answer is ["A","B","D"]
Explanation
A. Aging increases the risk for osteoporosis due to natural bone density loss over time.
B. Secondhand smoke contributes to bone loss and increases the risk for osteoporosis.
C. Obesity is not a known risk factor for osteoporosis; in fact, being overweight may have a protective effect on bone density.
D. Caffeine intake is associated with increased calcium loss, which can contribute to osteoporosis.
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