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 D
Explanation
A. Delayed fine-motor development is not typically an early or defining feature of Duchenne's muscular dystrophy (DMD); gross motor delays are more characteristic.
B. In DMD, the calf muscles may appear enlarged (pseudohypertrophy)due to fat and connective tissue replacing muscle, not true atrophy in early stages.
C. Holding onto furniture is more characteristic of toddlers with normal or delayed gross motor development, not specific to DMD.
D. Frequent falls and clumsinessare hallmark early signsof DMD, reflecting progressive muscle weakness, especially in the pelvic and thigh muscles.
Correct Answer is B
Explanation
A. Simple partial (focal aware) seizures do not alter consciousness; that is a characteristic of complex partial seizures.
B. Focal (partial) seizures typically affect one hemisphereof the brain and therefore one side of the body.
C. Seizures that begin with motor impairment in all extremitiessuggest a generalized seizure, not a simple partial seizure.
D. This is inaccurate. Simple partial seizures are treatablewith antiepileptic medications and sometimes surgical interventions.
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