The nurse is caring for a patient with a blunt trauma and tissue injury to the lower extremity. Which signs could develop in a patient with compartment syndrome?

Numbness and tingling in the opposite extremity

Severe. Increasing pain that is not relieved with opioids

Absence of pain in the affected extremity

Increased pain in the affected extremity upon ambulation

Answer and Explanation

The Correct Answer is B

A. Numbness and tingling in the opposite extremity: These symptoms might suggest a neurological issue but are not related to compartment syndrome, which is localized to the affected limb and involves pressure within a muscle compartment.
B. Severe, increasing pain that is not relieved with opioids: This is a hallmark sign of compartment syndrome. The pain is disproportionate to the injury and does not respond to usual pain management, indicating increased pressure within the compartment.
C. Absence of pain in the affected extremity: Absence of pain is not a symptom of compartment syndrome. In fact, severe pain is one of the primary symptoms, along with other signs like swelling and decreased sensation.
D. Increased pain in the affected extremity upon ambulation: While pain with movement can occur with many conditions, in compartment syndrome, the severe pain typically occurs regardless of movement and is related to the pressure within the muscle compartment, not just with ambulation.

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Correct Answer is A

Explanation

A. Assist the patient to turn to her side: This is the priority action to prevent aspiration of vomitus, which can be a serious complication for stroke patients who may have impaired swallowing and a reduced gag reflex.
B. Give an antiemetic as ordered: While important, administering an antiemetic should come after ensuring the patient’s safety and preventing aspiration.
C. Perform a test for blood on the emesis: This is not the immediate priority. Preventing aspiration is the first concern.
D. Call for an aide to get suction set up: Suction may be necessary if the patient is at risk of aspiration, but the first step is to turn the patient to prevent choking and aspiration.

A. Increase the client's oral fluid intake. B. Obtain a pair of slipper socks for the client. C. Rub the client's feet briskly for several minutes. D. Place a moist heating pad under the client's feet.

Correct Answer is B

Explanation

A. Increase the client's oral fluid intake.: While staying hydrated is generally good, it doesn't directly address the issue of cold feet caused by reduced circulation.
B. Obtain a pair of slipper socks for the client.: Slipper socks can help keep the feet warm without constricting blood flow, which is important for comfort and promoting circulation.
C. Rub the client's feet briskly for several minutes.: Vigorous rubbing could potentially cause injury or worsen circulation issues due to the fragility of the tissues in vascular compromise.
D. Place a moist heating pad under the client's feet.: Moist heat is not recommended as it can increase the risk of burns and injury, especially if the client has reduced sensation due to vascular occlusion.

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The nurse is caring for a patient with a blunt trauma and tissue injury to the lower extremity. Which signs could develop in a patient with compartment syndrome?

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Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is B

Explanation

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