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 C

Explanation

A. "Define the problem.": While defining the problem is important in the early stages of performance improvement, evaluating effectiveness requires looking at data or outcomes, not just the initial identification of the issue.

B. "Identify data collection methods.": Identifying data collection methods is part of the planning phase, but evaluating the effectiveness involves reviewing actual data to see if the goals of the program were achieved.

C. "Perform chart audits.": This is correct. Performing chart audits allows the nurse to assess if the desired improvements have been implemented and whether the performance outcomes are being met. Chart audits are a common method for evaluating the effectiveness of a performance improvement program.

D. "Review the facility's policy and procedure manual.": While reviewing policies is important for understanding standards of care, it does not directly evaluate the effectiveness of a performance improvement program. Data from actual practice, such as chart audits, would be more relevant for evaluation.

A. “I can make several office visits, so my child does not get so many immunizations at once.” B. "I understand that immunizations will be withheld if my child has lactose intolerance." C. "My child will need to start the human papillomavirus series when he enters kindergarten." D. "It is recommended that my child receive his first flu immunization at the age of 6."

Correct Answer is D

Explanation

A. “I can make several office visits, so my child does not get so many immunizations at once.”: This is incorrect. It is recommended that children receive multiple immunizations during a single office visit to help ensure they are fully vaccinated on time. Spacing out immunizations is not typically recommended unless there is a specific medical concern.

B. "I understand that immunizations will be withheld if my child has lactose intolerance.": This is incorrect. Lactose intolerance does not contraindicate immunizations. Some vaccines may contain small amounts of lactose, but this does not prevent a child with lactose intolerance from receiving them.

C. "My child will need to start the human papillomavirus series when he enters kindergarten.": This is incorrect. The human papillomavirus (HPV) vaccine is recommended to be started at ages 11 or 12, not when the child enters kindergarten.

D. "It is recommended that my child receive his first flu immunization at the age of 6.": This is correct. The first flu vaccine is recommended for children aged 6 months and older, and the initial flu vaccine may require two doses for children under 9 years of age, spaced at least 4 weeks apart.

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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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Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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