The nurse is caring for a client who develops compartment syndrome from a severely fractured arm. The client asks the nurse why this can happen. What is the best response by the nurse?
A bone fragment has injured the nerve supply in the area.
An injured artery causes impaired arterial perfusion through the compartment.
Bleeding and swelling cause increased pressure in an area that cannot expand.
The fascia expands with injury, causing pressure on underlying nerves and muscles.
The Correct Answer is C
Choice A reason: A bone fragment has injured the nerve supply in the area is not the best response by the nurse. This may be a possible complication of a fracture, but it does not explain the mechanism of compartment syndrome. Compartment syndrome is a condition where the pressure within a closed space (such as a muscle compartment) exceeds the perfusion pressure and causes ischemia and necrosis of the tissues. A bone fragment may damage the nerve, but it does not cause increased pressure in the compartment.
Choice B reason: An injured artery causes impaired arterial perfusion through the compartment is not the best response by the nurse. This may be a possible cause of compartment syndrome, but it is not the most common one. Compartment syndrome is more often caused by venous obstruction than arterial obstruction. An injured artery may reduce the blood flow to the compartment, but it does not cause increased pressure in the compartment.
Choice C reason: Bleeding and swelling cause increased pressure in an area that cannot expand is the best response by the nurse. This is the most common cause of compartment syndrome and explains the pathophysiology of the condition. Bleeding and swelling are the result of inflammation and tissue injury that occur after a fracture. They increase the volume of fluid in the compartment, which cannot expand due to the rigid fascia that surrounds it. This leads to increased pressure in the compartment, which compresses the blood vessels, nerves, and muscles and causes ischemia and necrosis of the tissues.
Choice D reason: The fascia expands with injury, causing pressure on underlying nerves and muscles is not the best response by the nurse. This is not a correct statement, as the fascia does not expand with injury. The fascia is a tough connective tissue that encloses the muscle compartments and limits their expansion. The fascia is part of the problem, not the cause, of compartment syndrome. The fascia prevents the compartment from accommodating the increased volume of fluid and causes increased pressure in the compartment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Inflammatory is the phase of wound healing that occurs at the time of injury and lasts about 35 days, because it is the first and immediate response to tissue damage. Inflammatory is the phase of wound healing that involves the activation of the immune system, the release of chemical mediators, the dilation of blood vessels, the increase of blood flow, the migration of white blood cells, and the formation of a clot. Inflammatory is the phase of wound healing that aims to control bleeding, prevent infection, and prepare the wound for healing.
Choice B reason: Proliferative is not the phase of wound healing that occurs at the time of injury and lasts about 35 days, but rather the phase of wound healing that occurs after the inflammatory phase and lasts about 23 weeks. Proliferative is the phase of wound healing that involves the growth and multiplication of new cells, the formation of granulation tissue, the synthesis of collagen, the contraction of the wound edges, and the development of epithelial tissue. Proliferative is the phase of wound healing that aims to fill the wound, restore the strength, and cover the defect.
Choice C reason: Maturation is not the phase of wound healing that occurs at the time of injury and lasts about 35 days, but rather the phase of wound healing that occurs after the proliferative phase and lasts about several months to years. Maturation is the phase of wound healing that involves the remodeling and reorganization of the collagen fibers, the reduction of scar tissue, the improvement of elasticity, and the restoration of function. Maturation is the phase of wound healing that aims to refine the wound, enhance the quality, and optimize the outcome.
Choice D reason: Intentional is not the phase of wound healing that occurs at the time of injury and lasts about 35 days, but rather a classification of wound healing that depends on the type and extent of tissue damage, the degree of contamination, and the method of closure. Intentional is a classification of wound healing that refers to wounds that are surgically created, have minimal tissue loss, are clean and sterile, and are closed by primary intention, which means that the wound edges are approximated with sutures, staples, or glue. Intentional is a classification of wound healing that results in faster healing, less scarring, and lower risk of infection.
Correct Answer is A
Explanation
Choice A reason: Using standard precautions is a practice that is recommended to prevent HIV transmission, because it is a set of guidelines that apply to all clients, regardless of their infection status, and that aim to prevent the exposure to blood, body fluids, or other potentially infectious materials. Standard precautions include hand hygiene, use of personal protective equipment, safe handling and disposal of sharps, environmental cleaning, and respiratory hygiene.
Choice B reason: Double gloving is not a practice that is recommended to prevent HIV transmission, because it is not proven to be more effective or safer than single gloving. Double gloving is a technique that involves wearing two pairs of gloves, one over the other, which may provide some extra protection against needlestick injuries or glove punctures, but may also reduce the tactile sensitivity, dexterity, or comfort of the wearer. Double gloving is not a routine practice, but rather an option for certain situations, such as highrisk procedures, long surgeries, or known HIVpositive clients.
Choice C reason: Applying hand sanitizer to gloves during cares is not a practice that is recommended to prevent HIV transmission, because it is not appropriate or hygienic. Applying hand sanitizer to gloves during cares is a practice that can damage the integrity and effectiveness of the gloves, as the alcohol or other chemicals can degrade the material, cause holes, or reduce the fit of the gloves. Applying hand sanitizer to gloves during cares can also create a false sense of security, as the gloves may still be contaminated or ineffective. Hand sanitizer should be applied to the hands before and after wearing gloves, not to the gloves themselves.
Choice D reason: Wearing a mask within three feet of the client is not a practice that is recommended to prevent HIV transmission, because it is not necessary or relevant. Wearing a mask within three feet of the client is a practice that is part of the droplet precautions, which are used to prevent the transmission of infections that are spread by large respiratory droplets, such as influenza, pertussis, or meningitis. HIV is not transmitted by respiratory droplets, but rather by sexual contact, blood, or other body fluids. Wearing a mask within three feet of the client may not provide any protection against HIV, and may also cause stigma or discrimination.
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