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 C

Explanation

Rationale:
A. Administer vasopressin to the client: Vasopressin helps control variceal bleeding by constricting splanchnic blood vessels. However, it cannot be safely or effectively administered until reliable IV access is confirmed, making it a secondary priority.

B. Request blood from blood bank: While the client may need transfusions to correct hypovolemia and blood loss, requesting blood is not the most immediate step. Before transfusion or medication, the nurse must ensure a functional IV line is available.

C. Verify that the client has adequate IV access: The priority in any hemorrhagic shock situation is to secure IV access to allow for fluid resuscitation, medication administration, and blood transfusion. Without IV access, no other interventions can be effectively implemented.

D. Insert an indwelling urinary catheter: Monitoring urine output is important in assessing renal perfusion and fluid status. However, this action does not address the immediate circulatory needs of the client and can be done after resuscitative access is secured.

A. Maintain scheduled daily routines for the client. B. Use long sentences when speaking with the client. C. Provide the client with increased environmental stimuli. D. Ensure all siderails are up on the client's bed when they are sleeping.

Correct Answer is A

Explanation

Rationale:
A. Maintain scheduled daily routines for the client: A consistent daily routine helps reduce confusion and anxiety in clients with Alzheimer’s disease by providing structure and familiarity. Predictability supports cognitive function and enhances a sense of security.

B. Use long sentences when speaking with the client: Long or complex sentences can overwhelm clients with moderate Alzheimer’s disease. Simple, short sentences with clear instructions are more effective for promoting understanding and cooperation.

C. Provide the client with increased environmental stimuli: Too much environmental stimulation can lead to agitation, confusion, or sensory overload in individuals with Alzheimer’s disease. A calm, quiet environment is more appropriate to help maintain focus and comfort.

D. Ensure all siderails are up on the client's bed when they are sleeping: Raising all side rails can pose a safety risk by increasing the likelihood of injury from attempts to climb over them. Alternatives like using a low bed and ensuring supervision are safer and more appropriate.

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