The nurse is caring for a client who sustained a crushed injury to the lower extremity and has developed compartment syndrome. What intervention should the nurse plan for next?

Insertion of central venous access

Phlebotomy

Fasciotomy

Insertion of arterial line

Answer and Explanation

The Correct Answer is C

A. Insertion of central venous access: This is not relevant to compartment syndrome management. Central venous access is used for fluid administration or monitoring central venous pressure.

B. Phlebotomy: This is unrelated to the management of compartment syndrome, as it involves drawing blood and does not address the increased pressure.

C. Fasciotomy: Compartment syndrome is a medical emergency where increased pressure within a closed compartment compromises circulation and tissue function. A fasciotomy involves surgically opening the compartment to relieve the pressure, prevent tissue necrosis, and save the limb. This is the definitive treatment.

D. Insertion of arterial line: While this may be useful for monitoring blood pressure in critical situations, it does not relieve compartment syndrome.

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Correct Answer is A

Explanation

A. “Brain death has occurred if there is no spontaneous breathing or brainstem reflexes.” Brain death is defined as the irreversible cessation of all functions of the entire brain, including the brainstem. The absence of spontaneous breathing and brainstem reflexes (such as pupillary response, gag reflex, and eye movements) are critical criteria used to confirm brain death.

B. “If respiratory efforts cease and no apical pulse is audible, brain death is present.” While the cessation of respiratory efforts is a key component of brain death, the presence or absence of an apical pulse alone is not sufficient for determining brain death. Brain death is determined based on the complete absence of brain function, including brainstem reflexes.

C. “Brain death has occurred if a person has flaccid muscles and does not awaken.” Muscle flaccidity and lack of consciousness may be signs of severe brain injury, but they do not necessarily confirm brain death. Brain death is diagnosed based on the absence of brainstem reflexes and spontaneous breathing.

D. “CPR does not restore a heartbeat, the brain cannot function.” While it is true that CPR may not restore circulation in brain-dead patients, this statement is incomplete and not a precise definition of brain death. Brain death is determined by the irreversible cessation of all brain activity, not just by the failure of CPR to restore circulation.

A. Intermittent claudication and pallor B. Jugular vein distention and dependent edema C. Diaphoresis and cool, clammy skin D. Mid-epigastric pain and heartburn

Correct Answer is C

Explanation

A. Intermittent claudication and pallor: These symptoms are more indicative of peripheral vascular disease, not a myocardial infarction.

B. Jugular vein distention and dependent edema. These symptoms suggest right-sided heart failure or fluid overload, not myocardial infarction.

C. Diaphoresis and cool, clammy skin. Diaphoresis (sweating) and cool, clammy skin are common signs of myocardial infarction due to the body's response to pain and decreased cardiac output.

D. Mid-epigastric pain and heartburn. While heartburn can mimic some symptoms of a heart attack, mid-epigastric pain and heartburn are more likely to be related to gastrointestinal issues rather than myocardial infarction.

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The nurse is caring for a client who sustained a crushed injury to the lower extremity and has developed compartment syndrome. What intervention should the nurse plan for next?

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Correct Answer is A

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