A nurse is providing discharge teaching to a client who has an implantable cardioverter/defibrillator (ICD). Which of the following information should the nurse include?

The client cannot travel by air due to security screening.

The client should hold his cell phone on the side opposite the ICD.

The client can carry his ICD in a small pocket.

The client should avoid the use of small electric devices.

Answer and Explanation

The Correct Answer is B

A. The client cannot travel by air due to security screening is incorrect; clients with ICDs can travel by air but should inform security personnel about the ICD.

B. The client should hold his cell phone on the side opposite the ICD to avoid interference with the ICD’s functioning.

C. The client can carry his ICD in a small pocket is incorrect; the ICD is implanted and does not need to be carried.

D. The client should avoid the use of small electric devices is not entirely accurate; the client should follow specific guidelines but not avoid all small devices.

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Correct Answer is D

Explanation

A. Flex the client’s hip is incorrect. Flexing the hip can increase intra-abdominal pressure and potentially increase intracranial pressure.

B. Hyperextend the client’s neck is incorrect. Hyperextension of the neck can interfere with venous return from the brain and increase ICP.

C. Provide warming measures for the client is incorrect. Warming measures are not indicated for a low CPP; maintaining normothermia is important, but warming is not the priority action.

D. Adjust the client’s head of bed is correct. Elevating the head of the bed helps reduce ICP and improves cerebral perfusion by promoting venous outflow.

Correct Answer is []

Explanation

1. Condition: Acute Compartment Syndrome

Justification: The presence of severe pain, swelling, numbness, and a weak radial pulse along with delayed capillary refill are classic signs of acute compartment syndrome. Immediate surgical intervention (fasciotomy) is necessary to relieve the pressure within the muscle compartments.

2. Actions to Take

Prepare for Fasciotomy:

Justification: This surgical procedure will relieve the internal pressure causing the symptoms.

Request Prescription for Pain Medication:

Justification: Adequate pain management is important for client comfort and can also indicate response to treatment.

3. Parameters to Monitor

Neurovascular Status:

Justification: Monitoring for further deterioration of symptoms such as worsening numbness or weak pulses is essential.

WBC Count:

Justification: Helps in the broader assessment of possible infection, though not directly related to acute compartment syndrome

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A nurse is providing discharge teaching to a client who has an implantable cardioverter/defibrillator (ICD). Which of the following information should the nurse include?

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Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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