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

Answer and Explanation

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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Correct Answer is B

Explanation

A. Administer an anti-anxiety medication is not the first action. The nurse should first assess and manage the client's environment and emotional state before resorting to medication.

B. Minimize environmental stimuli in the client's surroundings is correct. The client is experiencing anxiety, and minimizing stimuli helps to reduce environmental triggers and can immediately alleviate distress.

C. Explore behaviors that have helped to reduce the client's anxiety in the past is a good intervention but should not be the first response. The immediate priority is to reduce the anxiety by controlling the environment.

D. Explain to the client that anxiety causes physical manifestations is helpful but should occur after the immediate anxiety-reduction measures are in place. Providing this information can be part of the therapeutic process but does not address the client’s immediate distress.

A. Patient care technician B. Psychologist C. Advanced practice nurse D. Social worker

Correct Answer is C

Explanation

A. Patient care technician is incorrect. A patient care technician (PCT) is typically responsible for assisting with basic care tasks, such as taking vital signs or helping with personal hygiene. A PCT is not qualified to assess or manage medication interactions.

B. Psychologist is incorrect. A psychologist specializes in mental health and behavior but does not have the expertise to manage or review medication interactions.

C. Advanced practice nurse is correct. An advanced practice nurse (APN), such as a nurse practitioner, has advanced education and training in pharmacology and the management of complex medication regimens. They can assess potential medication interactions and provide guidance on safe medication use.

D. Social worker is incorrect. While a social worker provides support in areas like coping with illness and accessing resources, they are not typically involved in managing or reviewing medication interactions.

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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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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