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 C
Explanation
Choice A reason: Deeply palpating the area for rebound tenderness is not the nurse's next action, because it is inappropriate and dangerous. Deeply palpating the area for rebound tenderness is a test that involves applying and releasing pressure on the abdomen, which can elicit pain or discomfort in the presence of peritonitis or appendicitis. Deeply palpating the area for rebound tenderness is not relevant or useful for the client's complaint of pain and burning in the right calf area, which may indicate a deep vein thrombosis (DVT), which is a blood clot in the deep veins of the leg. Deeply palpating the area for rebound tenderness can also worsen the pain, damage the tissues, or dislodge the clot, which can cause pulmonary embolism, which is a lifethreatening condition.
Choice B reason: Percussing over the area for a change in tone is not the nurse's next action, because it is inappropriate and useless. Percussing over the area for a change in tone is a test that involves tapping on the chest or abdomen, which can produce different sounds depending on the density of the underlying organs or tissues. Percussing over the area for a change in tone is not relevant or useful for the client's complaint of pain and burning in the right calf area, which may indicate a deep vein thrombosis (DVT), which is a blood clot in the deep veins of the leg. Percussing over the area for a change in tone can also worsen the pain, damage the tissues, or dislodge the clot, which can cause pulmonary embolism, which is a lifethreatening condition.
Choice C reason: Comparing the circumference to the left calf is the nurse's next action, because it is appropriate and useful. Comparing the circumference to the left calf is a test that involves measuring the size of the leg, which can reveal any swelling or edema in the affected area. Comparing the circumference to the left calf is relevant and useful for the client's complaint of pain and burning in the right calf area, which may indicate a deep vein thrombosis (DVT), which is a blood clot in the deep veins of the leg. Comparing the circumference to the left calf can also help diagnose, monitor, or treat the condition, as a difference of more than 2 cm between the legs can suggest a DVT.
Choice D reason: Medicating the client for pain and reassessing in 60 minutes is not the nurse's next action, because it is inappropriate and delayed. Medicating the client for pain and reassessing in 60 minutes is an intervention that involves giving the client a painkiller and checking the response after an hour. Medicating the client for pain and reassessing in 60 minutes is not relevant or useful for the client's complaint of pain and burning in the right calf area, which may indicate a deep vein thrombosis (DVT), which is a blood clot in the deep veins of the leg. Medicating the client for pain and reassessing in 60 minutes can also mask the symptoms, delay the diagnosis, or miss the opportunity to prevent the complications, such as pulmonary embolism, which is a lifethreatening condition.
Correct Answer is B
Explanation
Choice A reason: A susceptible host is not an infectious disease, but a factor that influences the transmission of an infectious disease. A susceptible host is a person who is vulnerable to infection due to factors such as age, health status, immunization, or genetic predisposition. A susceptible host may become infected by a communicable disease, but it is not the disease itself.
Choice B reason: A communicable disease is an infectious disease that can be transmitted directly from one person to another. A communicable disease is caused by a pathogen, such as a virus, bacterium, fungus, or parasite, that can spread through contact, droplet, airborne, vector, or vehicle transmission. Examples of communicable diseases are influenza, tuberculosis, measles, malaria, and HIV/AIDS.
Choice C reason: A portal of entry to a host is not an infectious disease, but a factor that influences the transmission of an infectious disease. A portal of entry to a host is a route through which a pathogen can enter the body of a susceptible host and cause infection. A portal of entry to a host may be a break in the skin, a mucous membrane, or a body opening, such as the mouth, nose, eyes, or genitals. A portal of entry to a host may facilitate the transmission of a communicable disease, but it is not the disease itself.
Choice D reason: A portal of exit from the reservoir is not an infectious disease, but a factor that influences the transmission of an infectious disease. A portal of exit from the reservoir is a route through which a pathogen can leave the body of an infected person or animal and reach another susceptible host. A portal of exit from the reservoir may be a body fluid, such as blood, saliva, urine, or feces, or a body part, such as the skin, hair, or nails. A portal of exit from the reservoir may enable the transmission of a communicable disease, but it is not the disease itself.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today