NCLEX Compartment syndrome

changes with comparement syndrome

-capillaries dilate increasing capillary and venous pressure -venous drainage decrease -edema occurs -edema causes pressure on nerve endings and pain occurs -sensory perception defecits (paresthesia) -pulses weaken

ACS can occur not only in musculoskeletal issue people but also

-severe burns -extensive insect bites or snakebites -massive infiltration of IV fluids

A client who has sustained a crush injury to the right lower leg reports numbness and tingling of the affected extremity. The skin of the right leg appears pale. Which is the nurse's first intervention? a. Assess pedal pulses. b. Apply oxygen by nasal cannula. c. Increase the IV flow rate. d. Document the finding.

A. Assess pedal pulses The symptoms represent early warning of acute compartment syndrome. In acute compartment syndrome, sensory deficits such as paresthesias precede changes in vascular or motor signs. If the nurse finds a decrease in pedal pulses, the health care provider should be notified as soon as possible.

A patient with comminuted fractures of the tibia and fibula is treated with open reduction and application of an external fixator. The next day, the patient complains of severe pain in the leg, which is unrelieved by ordered analgesics. The patient's toes are pink, but the patient complains of numbness and tingling. The most appropriate action by the nurse is to a. Notify the patient's health care provider. b. Check the patient's blood pressure. c. Assess the external fixator pins for redness or drainage. d. Elevate the extremity and apply ice over the wound site.

A. Notify the patient's healthcare provider. The patient's clinical manifestations point to compartment syndrome and delay in diagnosis, and treatment may lead to severe functional impairment. There is no reason to suspect that patient's symptoms are caused by hypotension or hypertension or by infection at the pin sites. Elevation of or ice application to the leg will decrease arterial flow and further reduce perfusion.

The nurse is caring for a client who develops compartment syndrome from a severely fractured arm. The client asks the nurse how this can happen. The nurse's response is based on the understanding that: a. A bone fragment has injured the nerve supply in the area b. An injured artery causes impaired arterial perfusion through the compartment c. Bleeding and swelling cause increased pressure in an area that cannot expand d. The fascia expands with injury, causing pressure on underlying nerves and muscles

C. Bleeding and swelling cause increased pressure in an area that cannot expand. Compartment syndrome is caused by bleeding and swelling within a compartment, which is lined by fascia that does not expand. The bleeding and swelling place pressure on the nerves, muscles, and blood vessels in the compartment, triggering the symptoms.

A client has an arm cast and reports that it feels really tight and the fingers are puffy. What is the nurse's best response? a. "Elevate your arm on two pillows and apply ice to the cast." b. "Continue to take ibuprofen (Motrin) until the swelling subsides." c. "It is normal for a new cast to feel a little tight for the first few days." d. "Please come to the clinic today to have your arm checked by the health care provider."

D. "Please come to the clinic today to have your arm checked by the health care provider. Puffy fingers and a feeling of tightness from the cast may indicate the development of compartment syndrome. The client should come to the clinic that day to be evaluated by the provider because delay of treatment can cause permanent damage to the extremity. Ice and Motrin are acceptable actions, but checking the cast is the priority because it ensures client safety. The nurse should not just reassure the client that this is normal.

a pt. has been treated for compartment syndrome by undergoing a fascitomoy. which nursing diagnosis is most appropriate? a. risk for infection b. chronic pain c. impaired gas exchange d. decreased cardiac output

a. risk for infection

a nurse determines a client understands teaching regarding compartment syndrome if he reports which early symptom? a. heat b. paresthesia c. skin pallor d. swelling

b. paresthesia

A middle-aged patient has a tight cast on the left lower leg. Which assessment finding would prompt the nurse to assess further for compartment syndrome? A. Diminished pulses B. Discoloration of some of the toes C. Tingling sensation of the upper leg D. Pain more intense than expected based on initial injury

D. Pain more intense than expected based on initial injury

The nurse is caring for a client with a fractured fibula. Which assessment prompts immediate action by the nurse? a. Reported pain of 4 on a scale of 0 to 10 b. Numbness and tingling in the extremity c. Swollen extremity where the injury occurred d. Reports of being cold in bed

b. Numbness and tingling in extremity The client with numbness and tingling of the extremity may be displaying the first signs of acute compartment syndrome. This is an acute problem that requires immediate intervention because of possible decreased circulation. Moderate pain and swelling is an expected assessment after a fracture. These findings can be treated with comfort measures. Being cold can be treated with additional blankets or by increasing the temperature of the room.

a pt. has developed compartment syndrome following application of a cast to a fractured tibia. which of the following responses is the most accurate for prompt action in treating compartment syndrome? a. decrease the level of pain b. prevent tissue death, which can occur 2-4 hours c. prevent further complications d. decrease swelling in the extremity

b. prevent tissue death, which can occur 2-4 hours

a pt. with a recent fracture is suspected of having compartment syndrome. assessment findings may include which symptom? a. body-wide decrease in bone mass b. a growth in and around the bone c. inability to perform active movement; pain with passive movement d. inability to perform passive movement: pain with active movement

c. inability to perform active movement; pain with passive movement

if compartement syndrome is not treated then

cyanosis, tingling, numbness, paresis, and necorsis occurs

The nurse is completing a neurovascular assessment on the patient with a tibial fracture and a cast. The feet are pulseless, pale, and cool. The patient says they are numb. What should the nurse suspect is occurring? a. Paresthesia b. Pitting edema c. Poor venous return d. Compartment syndrome

d. Compartment syndrome

Patients w ACS may need a surgical procedure called

fasciotomy surgeon cuts through the fascia to relieve pressure and tension on vital blood vessels and nerves

https://paraquee.com/compartment-syndrome-nclex-questions-quizlet

https://paraquee.com/compartment-syndrome-nclex-questions-quizlet

long term problems from comparement syndrome

infection motor weakness contracture renal failure extreme cases: ambutation

comparement syndrome

serious, limb-threatening condition in which increased pressure within one or more comparements reduces circulation to lower leg and forearm