A nurse is monitoring a client's lower extremity following the placement of a cast earlier in the day. Which of the following findings should the nurse identify as manifestations of compartment syndrome? (Select all that apply.)
Pale-colored toes
Decreased skin turgor
Pain relieved by analgesia
Diminished capillary refill
Sensation of tingling
Correct Answer : A,D,E
A. Pale-colored toes are a sign of compromised circulation, which is a key manifestation of compartment syndrome. Decreased blood flow to the affected limb can cause pallor, which requires immediate intervention to prevent permanent damage.
B. Decreased skin turgor is incorrect. Skin turgor is an indicator of hydration status and is not directly related to compartment syndrome.
C. Pain relieved by analgesia is incorrect. One of the hallmark signs of compartment syndrome is severe pain that is not relieved by analgesia and worsens with passive movement.
D. Diminished capillary refill is correct. Delayed capillary refill (longer than 2 seconds) suggests poor perfusion, which can indicate increased pressure within the compartment.
E. Sensation of tingling is correct. Paresthesia (tingling or numbness) is an early sign of nerve compression due to swelling within the compartment. If untreated, this can progress to permanent nerve and muscle damage.
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Related Questions
Correct Answer is B
Explanation
A. To stay with the client's body for 8 hr following their death: While it is common for family members to stay with the deceased, the duration of time can vary and is not specifically aligned with Hindu customs.
B. To cremate the client's body: In Hinduism, cremation is the most common practice following death. The family is likely to request this as it aligns with religious beliefs and traditions.
C. To prohibit medical personnel from touching the client's body: In Hinduism, there is no blanket prohibition against medical personnel touching the body. However, some families may have specific requests for the handling of the body, but this is not universally expected.
D. To bury the client's body within 24 hr of their death: Hindus typically prefer cremation rather than burial. While burial is practiced in certain Hindu traditions, cremation is far more common, and the request for burial within 24 hours may not apply.
Correct Answer is C
Explanation
A. Documenting in the nursing care plan is incorrect. The nursing care plan outlines interventions and client needs, but it is not used for documenting medication errors.
B. Recording in the controlled substance inventory record is incorrect. While the administration of a controlled substance must be recorded, the inventory record tracks medication usage and does not serve as documentation for errors.
C. Completing an incident report is correct. An incident report is used to document medication errors, allowing for review and quality improvement measures to prevent future occurrences.
D. Writing in the provider's progress notes is incorrect. The provider's progress notes focus on client status and treatment plans, not internal error reporting. However, the nurse should notify the provider about the error.
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