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.

Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A respiratory rate of 8 breaths per minute with shallow respirations and cyanosis indicates severe respiratory distress or failure. In this situation, the client's oxygenation is compromised, and immediate intervention is needed to ensure an open and unobstructed airway. The nurse should prioritize ensuring the client has a patent airway by assessing for any airway obstruction and taking appropriate measures to clear the airway if necessary. This may involve techniques such as the head tilt-chin lift or jaw thrust maneuver.
While administering oxygen, checking the client's pulse rate, and placing a pulse oximeter on the client's finger are all important interventions in managing respiratory distress, the first and most critical step is to establish a patent airway. Without a clear airway, the client's oxygenation cannot be adequately addressed, and other interventions may be ineffective. Once the airway is secured, the nurse can proceed with providing oxygen, assessing the client's vital signs, and monitoring oxygen saturation using a pulse oximeter.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}
Explanation
Compartment syndrome occurs when there is increased pressure within a closed muscle compartment, leading to reduced blood flow to the muscles and nerves in that compartment. In this case, the open fracture and subsequent reduction and stabilization procedure can cause swelling and increased pressure within the affected compartment. This can impede blood flow and potentially lead to tissue damage. Common symptoms include severe pain, swelling, numbness, and decreased or absent pulses. Immediate medical attention is necessary if compartment syndrome is suspected.
Deep Vein Thrombosis (DVT) refers to the formation of blood clots within the deep veins, typically in the lower extremities. In the case of a client with an open fracture and immobilization with a splint, the risk of DVT increases due to factors such as reduced mobility, injury to blood vessels, and blood stasis. DVT can lead to serious complications if a clot dislodges and travels to the lungs, causing a pulmonary embolism. Symptoms of DVT may include pain, swelling, warmth, and redness in the affected limb.
While osteomyelitis and fat embolism syndrome can occur as complications of long bone fractures, they are not explicitly mentioned in the given scenario. Osteomyelitis refers to an infection in the bone, which can develop if bacteria enter an open fracture. Fat embolism syndrome can occur when fat globules from the bone marrow enter the bloodstream, usually following a long bone fracture.

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