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 ["D","E"]
Explanation
A. Assessment of Lower Extremities
Edema is common in renal failure but not specific to transplant rejection.
B. Sodium Level
Sodium level changes can occur with various conditions but are not specific to transplant rejection.
C. Lung Sounds
Lung sounds are important for respiratory issues but not directly indicative of kidney transplant rejection.
D. Creatinine Level
Elevated creatinine indicates possible kidney dysfunction or rejection.
E. Assessment of Incision Site
Signs of infection or inflammation at the incision site could indicate transplant issues.
F. Bowel Sounds
Hypoactive bowel sounds are related to gastrointestinal issues, not directly to transplant rejection.
G. Blood Pressure
Elevated blood pressure can be a consequence of many conditions but is not specific for transplant rejection.
Correct Answer is ["C","D"]
Explanation
A. Modern pacemakers are designed to withstand interference from microwave ovens, so it is not necessary to avoid having them in the home.
B. Airport security staff should be informed about the pacemaker, but handheld metal detectors should be avoided because prolonged exposure can interfere with pacemaker function. Instead, the client should request a manual search.
C. Monitoring the pulse daily helps to ensure the pacemaker is functioning properly and to detect any irregularities early.
D. Wearing tight clothing over the insertion area can cause discomfort and may interfere with the function of the pacemaker.
E. Activities that involve jolting or the risk of impact to the pacemaker should be avoided until cleared by a healthcare provider, and this period may extend beyond 4 weeks.
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