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":{"answers":"B"},"B":{"answers":"A,B"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A,B"}}
Explanation
1. Provider Consult
Angina: Not typically associated with immediate provider consultation.
MI: Requires immediate consultation for treatment decisions, such as medication or interventions.
2. Client's Initial Report of Manifestations
Angina: Can present with discomfort or pressure that is transient and relieved by rest or nitroglycerin.
MI: Can present similarly but is often more severe and sustained; discomfort may be a precursor to a myocardial infarction.
3. Treadmill Stress Test
Angina: Often used to provoke symptoms under controlled conditions for diagnosis.
MI: Not used during an acute phase; rather, diagnostics are performed through EKG and cardiac enzyme tests.
4. Result of Nitroglycerin Therapy
Angina: Relief from nitroglycerin indicates angina.
MI: Nitroglycerin might not provide relief; other treatments and diagnostics are needed.
5. 12 Lead EKG Report
Angina: ST depression and T-wave inversion can occur with angina.
MI: These EKG changes can indicate ischemia, which could be part of an acute MI if accompanied by other severe symptoms or in the presence of persistent symptoms.
Correct Answer is C
Explanation
A. Dobutamine does not directly affect blood glucose levels.
B. While dobutamine can increase heart rate, this is not a primary indicator of its effectiveness in treating heart failure.
C. Increased urine output indicates improved cardiac output and kidney perfusion, suggesting that dobutamine is effectively enhancing the heart's pumping ability.
D. Dobutamine may cause a slight decrease in blood pressure, but this is not a primary measure of its effectiveness in heart failure treatment.
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