An 18-year-old male patient arrives at the emergency department.
He has a cast to his lower leg.
He explains that he is in severe pain unrelieved by analgesics, paresthesia in his toes, and the nurse notes decreased capillary refill.
What is the most appropriate initial nursing intervention for this patient?
Perform a fasciotomy to relieve the pressure in the compartment.
Loosen the cast dressings or bandages on the affected limb.
Elevate the affected limb above heart level to decrease swelling.
Apply ice to the affected area to reduce swelling.
The Correct Answer is B
Choice A rationale
Performing a fasciotomy is a surgical procedure, not an initial nursing intervention. While it may be necessary to relieve compartment syndrome, it is outside the scope of nursing practice and is typically performed by a physician. The nurse's role is to identify the signs and symptoms and escalate to the medical team for this definitive treatment.
Choice B rationale
Loosening the cast dressings or bandages directly addresses the potential cause of compartment syndrome by reducing external compression. This action aims to improve blood flow and nerve function by alleviating pressure on the neurovascular structures within the confined space. This can prevent further tissue ischemia and damage.
Choice C rationale
Elevating the affected limb above heart level can paradoxically worsen compartment syndrome. Elevation decreases arterial perfusion pressure, further compromising blood flow to the already ischemic tissues within the rigid fascial compartment. This can exacerbate tissue hypoxia and cellular damage, increasing the risk of irreversible injury.
Choice D rationale
Applying ice to the affected area causes vasoconstriction, which would further reduce blood flow to the compromised tissues within the compartment. This decrease in perfusion would exacerbate ischemia and hypoxia, potentially worsening tissue damage and accelerating the progression of compartment syndrome. Therefore, ice application is contraindicated.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
While transgender individuals face unique challenges that can impact mental health, global statistics consistently show that male individuals as a demographic group have the highest completed suicide rates. This choice does not reflect the broader epidemiological data on suicide mortality across sexes.
Choice B rationale
Non-binary individuals, similar to transgender individuals, experience significant stressors that can contribute to mental health issues. However, when examining global suicide rates categorized by sex, the data predominantly indicates that males have higher completed suicide rates compared to other gender identities.
Choice C rationale
Globally, female individuals tend to have higher rates of attempted suicide and suicidal ideation, but male individuals consistently have higher completed suicide rates. This disparity is often attributed to males using more lethal means and potentially less frequent seeking of mental health support.
Choice D rationale
Globally, male individuals consistently exhibit a higher completed suicide rate compared to female individuals. This phenomenon is observed across various cultures and is often linked to factors such as higher use of lethal methods, societal pressures, and potentially lower rates of seeking mental health assistance.
Correct Answer is D
Explanation
Choice A rationale
Acupressure involves applying pressure to specific points on the body, aiming to stimulate energy flow and relieve pain. While it can promote relaxation and analgesia by releasing endorphins, its direct effect on significantly reducing blood pressure and respiratory rate in acute anxiety may be less pronounced compared to methods emphasizing controlled breathing techniques.
Choice B rationale
Effleurage is a light, stroking massage, typically applied to the abdomen during contractions. This technique can distract from pain and promote relaxation by stimulating large nerve fibers, thereby reducing pain perception. However, its primary physiological impact is generally on pain modulation and comfort, rather than a direct, strong reduction in elevated blood pressure and respiratory rate.
Choice C rationale
The Bradley method, also known as "husband-coached childbirth," emphasizes natural childbirth, focusing on deep abdominal breathing, relaxation, and partner support. While it promotes a calm environment and can reduce overall stress, its specific techniques for immediate physiological regulation of acutely elevated blood pressure and erratic respirations may not be as direct as methods specifically teaching controlled breathing.
Choice D rationale
The Lamaze method focuses on controlled breathing and relaxation techniques during labor. These techniques, particularly patterned breathing, directly influence the autonomic nervous system by increasing vagal tone, which can lead to a decrease in heart rate and respiratory rate, thereby lowering blood pressure and promoting a sense of calm during periods of anxiety.
Choice E rationale
Yoga incorporates physical postures, breathing exercises (pranayama), and meditation. While highly effective for long-term stress reduction and improving cardiovascular health, its immediate application in a laboring client experiencing acute anxiety with elevated vital signs might be less practical for immediate physiological regulation compared to targeted breathing methods like Lamaze.
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