A nurse is assisting with the care of a school-age child who recently returned to the PACU following pin placement for a radial head fracture with casting. Which of the following findings should the nurse monitor when conducting a circulatory check for compartment syndrome?
Edema.
Mottling.
Urticaria.
Pulselessness.
The Correct Answer is D
Choice A rationale:
Edema. Edema, the accumulation of fluid in the tissues, is not the primary indicator of compartment syndrome. While edema can occur due to various reasons, it's not specific to compartment syndrome. Compartment syndrome primarily involves increased pressure within a closed space (muscle compartment), which can compromise blood circulation and nerve function.
Choice B rationale:
Mottling. Mottling refers to a patchy, bluish discoloration of the skin that occurs due to poor blood circulation and is often seen in critically ill patients. While it might indicate circulatory issues, it's not a direct sign of compartment syndrome. Compartment syndrome is more closely associated with symptoms such as severe pain, numbness, and decreased or absent pulses.
Choice C rationale:
Urticaria. Urticaria, also known as hives, is a skin rash characterized by raised, itchy, and red or white welts. It is typically caused by an allergic reaction or other factors such as medications. Urticaria is unrelated to compartment syndrome, which involves the compression of nerves and blood vessels within a closed anatomical compartment, leading to ischemia and potential tissue damage.
Choice D rationale:
Pulselessness. Pulselessness is a critical sign that the nurse should monitor when conducting a circulatory check for compartment syndrome. Compartment syndrome occurs when there is increased pressure within a confined space (muscle compartment), leading to compromised blood flow and oxygen delivery to the tissues. The lack of a palpable pulse in the affected area suggests that blood flow is severely compromised. This is a late sign of compartment syndrome and requires immediate intervention to prevent tissue necrosis and long-term complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Administer two puffs of albuterol. This is the correct answer because albuterol is a bronchodilator that helps to relieve acute asthma symptoms by opening up the airways. In a child experiencing difficulty breathing due to asthma, prompt administration of albuterol can help alleviate the symptoms and improve breathing.
Choice B rationale:
Place the child in the supine position. Placing the child in the supine position can further compromise their breathing, especially in a situation of asthma exacerbation. This position can restrict the airways and make breathing more difficult, so it is not an appropriate action.
Choice C rationale:
Encourage the use of a flutter mucus clearance device. While mucus clearance devices can be helpful for individuals with chronic respiratory conditions, such as cystic fibrosis, it is not the priority action for a child experiencing acute asthma symptoms. The immediate focus should be on relieving the airway constriction and addressing the breathing difficulty.
Choice D rationale:
Instruct the child to perform controlled breathing exercises. Controlled breathing exercises might be useful for anxiety and panic management, but in an acute asthma episode, the child's primary need is to open up the airways and improve breathing. Albuterol administration takes precedence over breathing exercises in this situation.
Correct Answer is B
Explanation
Choice A rationale:
A 15-year-old client who requests testing for a sexually transmitted infection (STI) is seeking healthcare related to sexual health, which is often considered confidential. In many jurisdictions, minors of a certain age (often 12 or older) have the legal right to consent to STI testing and treatment without parental consent. While education on sexual health and responsible decision-making is important, in this case, the nurse may not need to involve the parent if the legal requirements are met.
Choice B rationale:
This is the correct answer. Minors generally require parental consent for medical procedures, including biopsies. A biopsy involves a medical intervention that can carry risks, and it is important to have informed parental consent for procedures on underage clients.
Choice C rationale:
A 16-year-old client who requires prenatal care for pregnancy is not applicable in this scenario. Prenatal care is focused on managing the health and well-being of a pregnant individual and their developing fetus. The question does not provide information that suggests this situation.
Choice D rationale:
A 13-year-old client who requests contraception advice may have the right to access contraception services without parental consent, depending on local laws and regulations. Many places allow minors to access contraception services confidentially, recognizing the importance of sexual health and preventing unintended pregnancies. However, it's always important for healthcare providers to assess each situation and the applicable legal framework to determine whether parental involvement is required.
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