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
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
b. Migraines with aura.
Explanation:
Migraines with aura are considered a contraindication to the use of oral contraceptives. Auras are neurological symptoms that occur before or during migraines and can include visual disturbances, sensory changes, or speech difficulties. Women who experience migraines with aura have an increased risk of ischemic stroke when taking oral contraceptives. Therefore, it is important to identify this condition as a contraindication and explore alternative contraceptive options for the client.
The other options (a. History of renal calculus, c. BMI of 25, d. History of cholecystectomy) are not contraindications to the use of oral contraceptives.
Correct Answer is C
Explanation
The nurse should inform the family that the client has the right to refuse medication. It is important to
respect the client's autonomy and right to make decisions about their own care.
a) Scheduling the medication at meal times does not address the issue of the client refusing their medication.
b) Requesting that the family talk to the provider about administering the medication by injection may be an option, but it does not address the issue of informed consent.
d) Asking the family what foods the client likes does not address the issue of informed consent and could be seen as a way to deceive the client into taking their medication.
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