A nurse is collecting data on a client who has swelling of the lower leg. The nurse should identify that which of the following findings is a manifestation of compartment syndrome?

Aﬀected extremity warm to touch

Moderate pain on the ankle of the aﬀected extremity

Blanch time of 2 seconds in the toenail beds of the aﬀected extremity

Palpation of a +1 dorsal pedal pulse of the aﬀected extremity

Answer and Explanation

The Correct Answer is B

A nurse collecting data on a client who has swelling of the lower leg should identify that moderate pain on the ankle of the aﬀected extremity is a manifestation of compartment syndrome. Compartment syndrome is a painful condition that occurs when pressure within a muscle compartment increases to dangerous levels.

The other options are not typical symptoms of compartment syndrome.

a) An aﬀected extremity being warm to touch is not a typical symptom of compartment syndrome.

c) A blanch time of 2 seconds in the toenail beds of the aﬀected extremity is not a typical symptom of compartment syndrome.

d) Palpation of a +1 dorsal pedal pulse of the aﬀected extremity is not a typical symptom of

compartment syndrome.

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Correct Answer is A

No explanation

A. Turn the newborn's head quickly to one side while they are sleeping. B. Place a finger in the newborn's palm. C. Clap hands after laying the newborn on a ﬂat surface. D. Hold the newborn upright with one foot touching the crib surface.

Correct Answer is C

Explanation

To elicit the Moro reﬂex, the nurse should clap hands after laying the newborn on a ﬂat surface. The Moro reﬂex, also known as the startle reﬂex, is an involuntary motor response that infants develop shortly after birth. Loud noises and sudden movements can trigger a baby’s Moro reﬂex.

Option a is incorrect because turning the newborn's head quickly to one side while they are sleeping may not elicit the Moro reﬂex.

Option b is incorrect because placing a finger in the newborn's palm may elicit the grasp reﬂex, not the Moro reﬂex.

Option d is incorrect because holding the newborn upright with one foot touching the crib surface may not elicit the Moro reﬂex.

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A nurse is collecting data on a client who has swelling of the lower leg. The nurse should identify that which of the following findings is a manifestation of compartment syndrome?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing a client who has a small bowel obstruction for insertion of a nasogastric tube. Which of the following equipment should the nurse gather prior to the procedure?

Correct Answer is A

A nurse in the newborn nursery is collecting data about a newborn's Moro reﬂex. Which of the following actions should the nurse take to elicit this reﬂex?

Correct Answer is C

Explanation

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