A nurse is caring for a 25yearold male quadriplegic client. Which of the following treatments would the nurse perform to decrease the risk of joint contracture and promote joint mobility?

Choice A reason: A bone fragment has injured the nerve supply in the area is not the best response by the nurse. This may be a possible complication of a fracture, but it does not explain the mechanism of compartment syndrome. Compartment syndrome is a condition where the pressure within a closed space (such as a muscle compartment) exceeds the perfusion pressure and causes ischemia and necrosis of the tissues. A bone fragment may damage the nerve, but it does not cause increased pressure in the compartment.

Choice B reason: An injured artery causes impaired arterial perfusion through the compartment is not the best response by the nurse. This may be a possible cause of compartment syndrome, but it is not the most common one. Compartment syndrome is more often caused by venous obstruction than arterial obstruction. An injured artery may reduce the blood flow to the compartment, but it does not cause increased pressure in the compartment.

Choice C reason: Bleeding and swelling cause increased pressure in an area that cannot expand is the best response by the nurse. This is the most common cause of compartment syndrome and explains the pathophysiology of the condition. Bleeding and swelling are the result of inflammation and tissue injury that occur after a fracture. They increase the volume of fluid in the compartment, which cannot expand due to the rigid fascia that surrounds it. This leads to increased pressure in the compartment, which compresses the blood vessels, nerves, and muscles and causes ischemia and necrosis of the tissues.

Choice D reason: The fascia expands with injury, causing pressure on underlying nerves and muscles is not the best response by the nurse. This is not a correct statement, as the fascia does not expand with injury. The fascia is a tough connective tissue that encloses the muscle compartments and limits their expansion. The fascia is part of the problem, not the cause, of compartment syndrome. The fascia prevents the compartment from accommodating the increased volume of fluid and causes increased pressure in the compartment.

Choice A reason: Calling the provider is not the intervention that the nurse should perform first, because it is not the most urgent and relevant action. Calling the provider is a communication intervention, not a respiratory intervention. Calling the provider is an important action, but it should be done after raising the head of the bed, and with accurate and complete information.

Choice B reason: Placing the client in the lithotomy position is not the intervention that the nurse should perform first, because it is not the most urgent and relevant action. Placing the client in the lithotomy position is a positioning intervention, not a respiratory intervention. Placing the client in the lithotomy position is a specific action that is used for pelvic examinations or procedures, not for improving oxygenation.

Choice C reason: Raising the head of the bed is the intervention that the nurse should perform first, because it is the most urgent and relevant action. Raising the head of the bed is a respiratory intervention, not a communication, positioning, or analgesic intervention. Raising the head of the bed is a simple and effective action that can improve the client's breathing, oxygenation, and comfort.

Choice D reason: Obtaining pain medication is not the intervention that the nurse should perform first, because it is not the most urgent and relevant action. Obtaining pain medication is an analgesic intervention, not a respiratory intervention. Obtaining pain medication is an important action, but it should be done after raising the head of the bed, and with a medical order and a proper route.