The nurse is caring for a patient who just returned from surgical decompression of the carpal tunnel. Which finding requires the nurse's immediate action?
The patient's fingers are pink and cool bilaterally.
The capillary refill time is 8 seconds.
The patient complains of generalized pain 5/10.
The patient's fingers swollen and warm.
The Correct Answer is B
A. Fingers being pink and cool bilaterally may be expected postoperatively due to anesthesia or positioning and does not indicate an immediate complication.
B. A capillary refill time of 8 seconds is significantly prolonged (normal is ≤2 seconds) and may indicate compromised circulation, possibly due to compartment syndrome or vascular compromise. This requires immediate action to preserve limb function.
C. A pain level of 5/10 is moderate and may be expected after surgery. It does not indicate an urgent issue unless unrelieved by medication or out of proportion to the procedure.
D. Swollen and warm fingers may be part of the normal inflammatory process after surgery but are not immediately life- or limb-threatening.
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Related Questions
Correct Answer is C
Explanation
A. Cerebral palsy (CP) varies widely in severity; not all individuals experience many disabilities.
B. CP is typically caused by decreased oxygen to the brain (hypoxia), not too much oxygen.
C. CP is a non-progressive neurological disorder, meaning the brain injury does not worsen over time, although symptoms may change.
D. CP is usually caused by brain injury before or during birth and is not typically inherited or familial.
Correct Answer is A
Explanation
A. Myasthenia gravis is an autoimmune disorder where antibodies attack acetylcholine receptors at the neuromuscular junction, leading to muscle weakness.
B. Inability of basal ganglia to produce sufficient dopamine is related to Parkinson’s disease, not myasthenia gravis.
C. A post-viral illness with ascending paralysis describes Guillain-Barré syndrome.
D. Loss of the myelin sheath surrounding peripheral nerves occurs in diseases like multiple sclerosis and peripheral neuropathies, not myasthenia gravis.
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