A nurse is caring for a young adult client in the emergency department.

Exhibits

For each assessment finding below, click to specify if the assessment finding is consistent with Compartment Syndrome, Fat Embolism Syndrome, or Deep Vein Thrombosis. Each finding may support more than one disease process.

Location of pain

Temperature of extremity

Respiratory assessment

Skin assessment

Nail bed assessment

Location of edema

Neurological status

Answer and Explanation

The Correct Answer is {"A":{"answers":"A,C"},"B":{"answers":"A,C"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"A"},"F":{"answers":"A,C"},"G":{"answers":"B"}}

Rationale:

Location of pain: Severe pain out of proportion to the injury, especially with passive stretch, is a classic sign of compartment syndrome. DVT also presents with localized pain in the affected limb, typically worsening over time due to venous congestion.
Temperature of extremity (Compartment Syndrome & DVT): A cool extremity in compartment syndrome indicates compromised arterial blood flow due to increased pressure within the fascial compartment. In DVT, the extremity may be warm early on, but impaired circulation can eventually result in coolness and cyanosis.
Nail bed assessment (Compartment Syndrome): Cyanotic or dusky nail beds reflect inadequate oxygen delivery from restricted blood flow, commonly seen in advanced compartment syndrome. This is a late and critical sign requiring urgent intervention to prevent permanent tissue damage.
Location of edema (Compartment Syndrome & DVT): Localized swelling occurs in compartment syndrome due to rising intracompartmental pressure. In DVT, venous obstruction leads to fluid accumulation and unilateral leg edema, often accompanied by warmth and discomfort.
Respiratory assessment (Fat Embolism Syndrome): FES often presents with sudden onset dyspnea, tachypnea, and hypoxemia due to fat globules entering the pulmonary circulation. These respiratory symptoms typically arise 24–72 hours after long bone trauma.
Skin assessment (Fat Embolism Syndrome): A petechial rash, especially on the chest, upper arms, and neck, is a distinguishing feature of FES. It results from occlusion of dermal capillaries by fat globules and is considered a hallmark sign of the condition.
Neurological status (Fat Embolism Syndrome): Altered mental status, confusion, and decreased alertness can occur in FES due to cerebral fat embolization. Neurologic involvement differentiates FES from other conditions like DVT or compartment syndrome, which typically do not cause cognitive changes.

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Correct Answer is ["A","E"]

Explanation

Rationale:

A. "I will take my temperature daily.": Daily temperature monitoring is essential for clients with neutropenia, as even a low-grade fever may be the only early sign of infection due to suppressed immune response. Prompt detection allows for early intervention and treatment.

B. "I will wash my toothbrush weekly.": A neutropenic client should wash or replace their toothbrush more frequently—ideally daily or after each use—to reduce the risk of bacterial growth and oral infections, which they are more vulnerable to.

C. "I will eat plenty of fresh fruits and vegetables.": Fresh, uncooked fruits and vegetables may carry harmful bacteria or fungi and should be avoided unless thoroughly washed or cooked. A neutropenic diet typically excludes raw produce to minimize infection risk.

D. "I will change my cat's litter box twice weekly.": Clients with neutropenia should avoid handling cat litter altogether, as it can harbor Toxoplasma gondii and other pathogens that pose a serious infection risk due to their weakened immune system.

E. "I will avoid crowds.": Avoiding crowds is critical for clients with neutropenia to reduce exposure to airborne and contact-transmissible pathogens, as even minor infections can become life-threatening in immunocompromised individuals.

A. Report of itching B. Distended jugular veins C. Report of low back pain D. Temperature 37.8° C (100° F)

Correct Answer is A

Explanation

Rationale:
A. Report of itching: Itching is a common early sign of an allergic transfusion reaction. These reactions occur due to sensitivity to plasma proteins in the donor blood and may also present with hives, flushing, or mild respiratory symptoms.

B. Distended jugular veins: Jugular vein distention is a sign of fluid overload or circulatory compromise, such as transfusion-associated circulatory overload (TACO), not an allergic reaction.

C. Report of low back pain: Low back pain is more indicative of an acute hemolytic reaction, which results from ABO incompatibility. This is a serious and life-threatening reaction distinct from allergic responses.

D. Temperature 37.8° C (100° F): A mild elevation in temperature may be seen with febrile non-hemolytic transfusion reactions, which are different from allergic reactions. Allergic reactions usually involve skin and respiratory symptoms.

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Naxlex Comprehensive Predictor Exams

A nurse is providing teaching for a client who has neutropenia and is receiving chemotherapy. Which of the following client statements indicates an understanding of the teaching? (Select all that apply.)

Correct Answer is ["A","E"]

Explanation

A nurse is monitoring a client who is receiving a unit of packed RBCs. Which of the following findings should the nurse identify as an indication that the client is having an allergic transfusion reaction?

Correct Answer is A

Explanation

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