Author Question: A nurse assesses a client with a cast for potential compartment syndrome. Which clinical ... (Read 132 times)

plus1 · **on:** Jun 25, 2018

A nurse assesses a client with a cast for potential compartment syndrome. Which clinical manifestations are correctly paired with the physiologic changes of compartment syndrome? (Select all that apply.)

a. Edema - Increased capillary permeability
b. Pallor - Increased blood blow to the area
c. Unequal pulses - Increased production of lactic acid
d. Cyanosis - Anaerobic metabolism
e. Tingling - A release of histamine

Question 2

A nurse plans care for a client who is recovering from open reduction and internal fixation (ORIF) surgery for a right hip fracture. Which interventions should the nurse include in this client's plan of care? (Select all that apply.)

a. Elevate heels off the bed with a pillow.
b. Ambulate the client on the first postoperative day.
c. Push the client's patient-controlled analgesia button.
d. Re-position the client every 2 hours.
e. Use pillows to encourage subluxation of the hip.

bulacsom · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

ANS: A, C, D
Clinical manifestations of compartment syndrome are caused by several physiologic changes. Edema is caused by increased capillary permeability, release of histamine, decreased tissue perfusion, and vasodilation. Unequal pulses are caused by an increased production of lactic acid. Cyanosis is caused by anaerobic metabolism. Pallor is caused by decreased oxygen to tissues, and tingling is caused by increased tissue pressure.

Answer to Question 2

ANS: A, B, D
Postoperative care for a client who has ORIF of the hip includes elevating the client's heels off the bed and re-positioning every 2 hours to prevent pressure and skin breakdown. It also includes ambulating the client on the first postoperative day, and using pillows or an abduction pillow to prevent subluxation of the hip. The nurse should teach the client to use the patient-controlled analgesia pump, but the nurse should never push the button for the client.