Neuromuscular Impairment

Which assessment finding found while assessing a patient with a fracture who has traction requires immediate intervention? A. The weights are freely hanging on the floor. B. Pin sites are free from drainage. C. Patient uses the overhead trapeze bar to move around in the bed. D. Patient's extremities have a capillary refill of less than 2 seconds.

A. The weights are freely hanging on the floor. Weights used for traction should freely hang but NOT on the floor. All the other options are expected findings.

A 3-month-old with spina bifida is admitted to the nurse's unit. Which of the following gross motor skills should the nurse assess at this age? 1. Head control. 2. Pincer grasp. 3. Sitting alone. 4. Rolling over.

1. A 3-month-old has good head control. TEST-TAKING HINT: The test taker must know normal developmental milestones.

The parent of a toddler newly diagnosed with CP asks the nurse what caused it. The nurse should answer which of the following? 1. Most cases are caused by unknown prenatal factors. 2. It is commonly caused by perinatal factors. 3. The exact cause is not known. 4. The exact cause is known in every instance.

1. At least 80% of cases of CP result from unknown prenatal factors TEST-TAKING HINT: The test taker must know the latest information to answer this question correctly.

A nurse is receiving an infant with myelomeningocele from an outside hospital. Which of the following priority items should be placed at the newborn's bedside? 1. A bottle of normal saline. 2. A rectal thermometer. 3. Extra blankets. 4. A blood pressure cuff.

1. Before the surgical closure of the sac, the infant is at risk for infection. A sterile dressing is placed over the sac to keep it moist and help prevent it from tearing. TEST-TAKING HINT: Focus on the care and potential complications of an infant with spina bifida to answer the question correctly

Which of the following will help a school-aged child with muscular dystrophy stay active longer? 1. Normal activities, such as swimming. 2. Using a treadmill every day. 3. Several periods of rest every day. 4. Using a wheelchair on getting tired.

1. Children who are active are usually able to postpone use of the wheelchair longer. It is important to keep using muscles for as long as possible, and aerobic activity is good for a child. TEST-TAKING HINT: Appropriate interventions for different kinds of chronically ill children can be similar, so think about what would be best for this child.

A child is admitted to the pediatric unit with spastic CP. Which of the following would the nurse expect this child to demonstrate? Select all that apply. 1. Increased deep tendon reflexes. 2. Decreased muscle tone. 3. Scoliosis. 4. Contractures. 5. Scissoring. 6. Good control of posture. 7. Good fine motor skills

1. Children with spastic CP have increased deep tendon reflexes. 3. Children with spastic CP have scoliosis. 4. Children with spastic CP have contractures of the Achilles tendons, knees, and adductor muscles. 5. Children with spastic CP have scissoring when walking. TEST-TAKING HINT: The test taker must know the typical signs of CP.

The mother of a child with Duchenne muscular dystrophy asks the nurse who in the family should have genetic screening. Who should the nurse say must be tested? Select all that apply. 1. The mother and father. 2. The sister. 3. The brother. 4. The aunts and all female cousins. 5. The uncles and all male cousins.

1. Genetic counseling is important in all inherited diseases. Duchenne muscular dystrophy is inherited as an X-linked recessive trait, meaning the defect is on the X chromosome. Women carry the disease, and males are affected. All female relatives should be tested. 2. Women carry the disease, and males are affected. All female relatives should be tested. 4. Women carry the disease, and males are affected. All female relatives should be tested TEST-TAKING HINT: Knowing that Duchenne muscular dystrophy is inherited as a X-linked trait excludes brother, uncle, and male cousins as carriers.

A 5-year-old has been diagnosed with pseudohypertrophic muscular dystrophy. Which of the following nursing interventions would be appropriate? 1. Discuss with the parents the potential need for respiratory support. 2. Explain that this disease is easily treated with medication. 3. Suggest exercises that will limit the use of muscles and prevent fatigue. 4. Assist the parents in finding a nursing facility for future care

1. Muscles become weaker, including those needed for respiration, and a decision will need to be made about whether respiratory support will be provided. TEST-TAKING HINT: Pseudohypertrophic muscular dystrophy is a progressive neuromuscular disease with no cure.

The parents of a preschooler diagnosed with muscular dystrophy are asking questions about the course of their child's disease. The nurse should tell them which of the following? 1. Muscular dystrophies are disorders associated with progressive degeneration of muscles, resulting in relentless and increasing weakness. 2. The weakness that the child is currently experiencing will probably not increase. 3. The child will be able to function normally and require no special accommodations. 4. The extent of degeneration depends on performing daily physical therapy

1. Muscular dystrophies are progressive degenerative disorders. The most common is Duchenne muscular dystrophy, which is an X-linked recessive disorder. TEST-TAKING HINT: The test taker should know that muscular dystrophy is a progressive degenerative disorder

A nurse is performing a well-child assessment on a 4-year-old child. The parent reports that the child often trips and falls while walking. Which of the following actions should the nurse take? 1. Notify the provider of this unexpected finding. 2. Reassure the parents the child will outgrow this behavior. 3. Inspect the child's shoes to see if the size is too big. 4. Ask the parent if the child is taking any medications that might cause tripping.

1. Notify the provider of the unexpected finding. Further examination and tests are needed to determine if there is a problem.

The parent of a 6-year-old with a repaired myelomeningocele is in the clinic for her child's regular examination. The child has frequent constipation and has been crying at night because of pain in the legs. After an MRI, the diagnosis of a tethered cord is made. Which of the following should the nurse tell the parent? 1. Tethered cord is a postsurgical complication. 2. Tethered cord occurs during times of slow growth. 3. Release of the tethered cord will be necessary only once. 4. Offering laxatives and acetaminophen daily will help control these problems.

1. Tethered cord is caused by scar tissue formation from the surgical repair of the myelomeningocele and may affect bowel, bladder, or lower extremity functioning TEST-TAKING HINT: Tethering is caused by scar tissue from any surgical intervention and may recur as the child grows

A newborn is diagnosed with a myelomeningocele at L2. Which of the following should be the priority nursing diagnosis for this infant at 12 hours of age? 1. Altered bowel elimination related to neurological deficits. 2. Potential for infection related to the physical defect. 3. Altered nutrition related to neurological deficit. 4. Disturbance in self-concept related to physical disability.

2. Because this infant has not had a repair, the sac is exposed. It could rupture, allowing organisms to enter the cerebrospinal fluid, so this is the priority. TEST-TAKING HINT: Before surgery, the myelomeningocele is exposed, so risk of infection is much higher.

Which of the following should the nurse tell the parent of an infant with spina bifida? 1. Bone growth will be more than that of babies who are not sick, because your baby will be less active. 2. Physical and occupational therapy will be helpful to stimulate the senses and improve cognitive skills. 3. Nutritional needs for your infant will be calculated based on activity level. 4. Fine motor skills will be delayed because of the disability

2. Children with decreased activity due to illness or trauma are helped by physical and occupational therapy. The varied activities stimulate the senses. TEST-TAKING HINT: The test taker should know normal growth patterns

The nurse is teaching family members of a child newly diagnosed with muscular dystrophy about early signs. The nurse knows that teaching was successful when a parent states that which of the following signs may indicate the condition early? 1. Increased muscle strength. 2. Difficulty climbing stairs. 3. High fevers and tiredness. 4. Respiratory infections and obesity.

2. Difficulty climbing stairs, running, and riding a bicycle are frequently the first symptoms of Duchenne muscular dystrophy TEST-TAKING HINT: Early symptoms have to do with decreased ability to perform normal developmental tasks involving muscle strength

A nurse is caring for a newborn with spina bifida. THe parents are very distraught. Which of the following interventions is appropriate? 1. Discuss placement options for the infant. 2. Emphasize positive attributes of the infant. 3. Encourage parents to resolve grief as soon as possible. 4. Avoid talking about the infant until the parents are ready to bring up the subject.

2. Emphasize positive attributes of the infant. Encouraging discussion of positive attributes promotes hope and positive feelings.

Which of the following should the nurse do first when caring for an infant who just had a repair of a myelomeningocele? 1. Weigh diapers for 24-hour urine output. 2. Measure head circumference. 3. Offer clear fluids. 4. Assess for infection

2. Hydrocephalus occurs in about 90% of infants with myelomeningocele, so measuring the head circumference daily and watching for an increase are important. Accumulation of cerebrospinal fluid can occur after closure of the sac. TEST-TAKING HINT: The dynamics of the cerebrospinal fluid change after closure of the sac.

A nurse is caring for an infant after a myelomeningocele repair. Which of the following is the priority post-operative nursing intervention? 1. Measure I&O. 2. Measure head circumference. 3. Asses lower extremity function. 4. Monitor blood pressure.

2. Measure head circumference. Hydrocephalus can occur as a complication of a myelomeningocele repair and is monitored by head circumference measurements.

A 2-month-old has had a myelomeningocele repair and has been brought in by a parent for the well-child checkup and shots. Over the last week, the baby has had a high-pitched cry and has been irritable. Height, weight, and head circumference have been at the 50th percentile. Today height is at the 50th percentile, weight is at the 70th percentile, and head circumference is at the 90th percentile. The nurse should do which of the following? 1. Tell the parent this is normal for an infant with a repaired myelomeningocele. 2. Tell the parent this might mean the baby has increased intracranial pressure. 3. Suspect the baby's intracranial pressure is low because of a leak. 4. Refer the baby to the neurologist for follow-up care.

2. The increase in head size is one of the first signs of increased intracranial pressure; other signs include highpitched cry and irritability TEST-TAKING HINT: The test taker should know how fast an infant's head size changes

A 3-year-old child with CP is admitted for dehydration following an episode of diarrhea. The nurse's assessment follows: awake, pale, thin child lying in bed, multiple contractures, drooling, coughing spells noted when parent feeds. T 97.8°F (36.5°C), P 75, R 25, weight 7.2 kg, no diarrheal stool for 48 hours. Which of the following nursing diagnoses is most important? 1. Potential for skin breakdown: lying in one position. 2. Alteration in nutrition: less than body requirements. 3. Potential for impaired social support: mother sole caretaker. 4. Alteration in elimination: diarrhea.

2. This is the priority nursing diagnosis for this severely underweight child. Weight is average for a 4-month-old. The coughing episodes while feeding may indicate aspiration. The parent needs help to learn how to feed so less coughing occurs. TEST-TAKING HINT: The test taker should convert the weight in kilograms to pounds

The nurse knows that teaching has been successful when the parent of a child with muscle weakness states that the diagnostic test for muscular dystrophy is which of the following? 1. Electromyelogram. 2. Nerve conduction velocity. 3. Muscle biopsy. 4. Creatine kinase level.

3. Muscle biopsy confirms the type of myopathy that the patient has. TEST-TAKING HINT: Muscle biopsy is the definitive test for myopathies.

The nurse is caring for an infant with myelomeningocele who is going to surgery later today for closure of the sac. Which of the following would be a priority nursing diagnosis before surgery? 1. Alteration in parent-infant bonding. 2. Altered growth and development. 3. Risk of infection. 4. Risk for weight loss.

3. A normal saline dressing is placed over the sac to prevent tearing, which would allow the cerebrospinal fluid to escape and microorganisms to enter and cause an infection. TEST-TAKING HINT: The preoperative priority is risk of infection, especially when effort is necessary to keep a sterile saline dressing on the sac.

A newborn with a repaired myelomeningocele is assessed for hydrocephalus. What would the nurse expect if the infant has hydrocephalus? 1. Low-pitched cry and depressed fontanel. 2. Low-pitched cry and bulging fontanel. 3. Bulging fontanel and downwardly rotated eyes. 4. Depressed fontanel and upwardly rotated eyes.

3. An alteration in the circulation of the cerebrospinal fluid causes hydrocephalus. The anterior fontanel bulges because of an increase in cerebrospinal fluid, and an increase in intracranial pressure causes a high-pitched cry in infants and downward deviation of the eyes, also called sunset eyes. With sunset eyes the sclera can be seen above the iris. TEST-TAKING HINT: The test taker must know the difference in clinical signs of hydrocephalus in infants and older children. Infants' heads expand, whereas older children's skulls are fixed. The anterior fontanel closes between 12 and 18 months

A child with spastic CP had an intrathecal dose of baclofen in the early afternoon. What is the expected result 31/2 hours post dose that suggests the child would benefit from a baclofen pump? 1. The ability to self-feed. 2. The ability to walk with little assistance. 3. If the spasticity were decreased. 4. If the spasticity were increased.

3. If baclofen were going to work for this patient, one could tell because spasticity would be decreased. TEST-TAKING HINT: The test taker must know the purpose of baclofen

The parent of an infant with CP asks the nurse if the infant will be mentally retarded. Which of the following is the nurse's best response? 1. "Children with CP have some amount of mental retardation." 2. "Approximately 20% of children with CP have normal intelligence." 3. "Many children with CP have normal intelligence." 4. "Mental retardation is expected if motor and sensory deficits are severe."

3. Many children with CP have normal intelligence. TEST-TAKING HINT: Children with CP have a wide range of intellectual abilities.

The nurse is caring for a newborn with a myelomeningocele who will have a surgical repair tomorrow. The nurse should do which of the following? 1. Offer formula every 3 hours. 2. Turn the infant back to front every 2 hours. 3. Place a wet dressing on the sac. 4. Provide pain medication every 4 hours.

3. Priority care for an infant with a myelomeningocele is to protect the sac. A wet dressing keeps it moist with less chance of tearing. TEST-TAKING HINT: Realizing the defect is on the back eliminates answer 2. Knowing newborns are sleepy and do not eat on a schedule eliminates answer 1.

Which of the following signs and symptoms of increased ICP after head trauma would appear first? 1. Bradycardia 2. Large amounts of very dilute urine 3. Restlessness and confusion 4. Widened pulse pressure

3. Restlessness and confusion The earliest symptom of elevated ICP is a change in mental status. Bradycardia, widened pulse pressure, and bradypnea occur later. The client may void large amounts of very dilute urine if there's damage to the posterior pituitary.

The nurse is teaching the parents of a child with Duchenne (pseudohypertrophic) muscular dystrophy. The nurse should tell them that some of the progressive complications include which of the following? 1. Dry skin and hair, hirsutism, protruding tongue, and mental retardation. 2. Anorexia, gingival hyperplasia, and dry skin and hair. 3. Contractures, obesity, and pulmonary infections. 4. Trembling, frequent loss of consciousness, and slurred speech.

3. The major complications of muscular dystrophy include contractures, disuse atrophy, infections, obesity, respiratory complications, and cardiopulmonary problems. TEST-TAKING HINT: The test taker should be able to identify signs and symptoms attributable to the loss of muscle function.

The parent of a young child with CP brings the child to the clinic for a checkup. Which of the parent's following statements indicates an understanding of the child's long-term needs? 1. "My child will need all my attention for the next 10 years." 2. "Once in school, my child will catch up and be like the other children." 3. "My child will grow up and need to learn to do things independently." 4. "I'm the one who knows the most about my child and can do the most for my child."

3. This statement indicates that the parent understands the long-term needs of the child. TEST-TAKING HINT: The test taker must understand the goals for children with chronic illnesses or disorders. One goal is to ensure that the child be diagnosed as early as possible so that interventions can be started. Another is to help the child realize as much potential as possible.

Following surgical repair and closure of a myelomeningocele shortly after birth, which of the following is true of an infant? 1. The infant will not need any long-term management and should be considered cured. 2. The infant will no longer be at risk of urinary tract infections or movement problems. 3. The infant will have continual drainage of cerebrospinal fluid, needing frequent dressing changes. 4. The infant will need lifelong management of urinary, orthopedic, and neurological problems

4. Although immediate surgical repair decreases infection, morbidity, and mortality rates, these children will require lifelong management of neurological, orthopedic, and elimination problems. TEST-TAKING HINT: The test taker can eliminate answer 1 due to the complexity of myelomeningocele.

A 15-year-old with spina bifida is seen in the clinic for a well-child checkup. The teen uses leg braces and crutches to ambulate. Which of the following nursing diagnoses takes priority? 1. Potential for infection. 2. Alteration in mobility. 3. Alteration in elimination. 4. Potential body image disturbance

4. As an adolescent on crutches and wearing braces, the teen would have the issue of body image disturbance, which must be addressed. This is a priority. TEST-TAKING HINT: The test taker must know normal development

The nurse is discussing nutrition with the parents of a child with Duchenne muscular dystrophy. The nurse tells the parents that which of the following foods would be best for their child? 1. High-carbohydrate, high-protein foods. 2. No special food combinations. 3. Extra protein to help strengthen muscles. 4. Low-calorie foods to prevent weight gain.

4. As the child becomes less ambulatory, moving the child will become more of a problem. It is not good for the child to become overweight for several health reasons in addition to decreased ambulation. TEST-TAKING HINT: Knowing that nutrition is important for every child as is awareness that as the child becomes less ambulatory, weight concerns arise.

The Gower sign for assessing Duchenne muscular dystrophy can be elicited by having a patient do which of the following? 1. Close the eyes and touch the nose with alternating index fingers. 2. Hop on one foot and then the other. 3. Bend from the waist to touch the toes. 4. Walk like a duck and rise from a squatting position.

4. Children with muscular dystrophy display the Gower sign, which is great difficulty rising and standing from a squatting position due to the lack of muscle strength. TEST-TAKING HINT: By eliminating cerebral activities, the test taker would know that the Gower sign assists in measuring leg strength

The parent of an infant asks the nurse what to watch for to determine if the infant has CP. The nurse should reply which of the following? 1. If the infant cannot sit up without support before 8 months. 2. If the infant demonstrates tongue thrust before 4 months. 3. If the infant has poor head control after 2 months. 4. If the infant has clenched fists after 3 months.

4. Clenched fists after 3 months of age may be a sign of CP. TEST-TAKING HINT: The test taker must know normal developmental milestones to identify those that are abnormal.

The nurse is caring for a school-aged child with Duchenne muscular dystrophy in the elementary school. Which of the following would be an appropriate nursing diagnosis? 1. Anticipatory grieving. 2. Anxiety reduction. 3. Increased pain. 4. Activity intolerance.

4. The child would not be able to keep up with peers because of weakness, progressive loss of muscle fibers, and loss of muscle strength. TEST-TAKING HINT: Knowing that the child has decreased strength helps to answer the question

The nurse knows that teaching of parents of a child newly diagnosed with CP is successful when the parents state that CP is which of the following? 1. Inability to speak and drooling. 2. Poor dentition due to poor hygiene. 3. Involuntary movements of upper extremities only. 4. An increase in muscle tone and deep tendon reflexes

4. The primary disorder is of muscle tone, but there may be other neurological disorders such as seizures, vision disturbances, and impaired intelligence. Spastic CP is the most common type and is characterized by a generalized increase in muscle tone, increased deep tendon reflexes, and rigidity of the limbs on both flexion and extension. TEST-TAKING HINT: The test taker must know the definition of CP.

The nurse is developing a plan of care for a child recently diagnosed with CP. Which of the following should be the nurse's priority goal? 1. Ensure the ingestion of sufficient calories for growth. 2. Decrease intracranial pressure. 3. Teach appropriate parenting strategies for a special-needs child. 4. Ensure that the child reaches full potential.

4. The priority for all children is to develop to their full potential. TEST-TAKING HINT: All of these are important goals, but determining the priority goal for a special-needs child is the key

Which of the following values is considered normal for ICP? A. 0-15 mm Hg B. 25 mm Hg C. 35-45 mm Hg D. 120/80 mm Hg

A. 0-15 mm Hg

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.

Your patient is 2 hours post-op from a cast placement on the right leg. The patient has family in the room. Which action by the significant other requires you to re-educate the patient and family about cast care? A. Gently moving the cast with the fingertips of the hands every 2 hours to help with drying. B. Elevating the cast above heart level with pillows. C. Checking the color and temperature of the right foot. D. Using a hair dryer on the cool setting to help with drying.

A. Gently moving the cast with the fingertips of the hands every 2 hours to help with drying. The cast should always be moved with the palms of the hands (NOT finger tips) during the drying period to prevent dent formation because this can cause the development of ulcers under the skin where the dents develop.

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.

Select all the signs and symptoms that will present in compartment syndrome? A. Capillary refill less than 2 seconds B. Pallor C. Pain relief with medication D. Feeling of tingling in the extremity E. Affected extremity feels cooler to the touch than the unaffected extremity

B, D, E These symptoms may present with compartment syndrome. Option A and C are normal findings. Remember in compartment syndrome nerve and blood vessel function is being compromised, so expect signs and symptoms that occur when these structures are affected.

Which statement by a patient, who just received a cast on the right arm for a fracture, requires you to notify the physician immediately? A. "It is really itchy inside my cast!" B. "My pain is so severe that it hurts to stretch or elevate my arm." C. "I can feel my fingers and move them." D. "I've been using ice packs to reduce swelling."

B. "My pain is so severe that it hurts to stretch or elevate my arm." The answer is B. This statement is very concerning and may represent a condition called compartment syndrome. Compartment syndrome is where the nerves and blood vessels are becoming compromised due to increasing pressure in the compartments within the fascia (remember fascia doesn't expand, so if there is building pressure within the compartments of muscle from bleeding etc. it will compromise circulation and nerve function). Remember to monitor the 6 P's. (pain, pallor, paralysis, paresthesia, pulselessness (late sign), poikilothermia)

A lumbar puncture is performed on a child suspected of having bacterial meningitis. CSF is obtained for analysis. A nurse reviews the results of the CSF analysis and determines that which of the following results would verify the diagnosis? A. Cloudy CSF, decreased protein, and decreased glucose B. Cloudy CSF, elevated protein, and decreased glucose C. Clear CSF, elevated protein, and decreased glucose D. Clear CSF, decreased pressure, and elevated protein

B. Cloudy CSF, elevated protein, and decreased glucose A diagnosis of meningitis is made by testing CSF obtained by lumbar puncture. In the case of bacterial meningitis, findings usually include an elevated pressure, turbid or cloudy CSF, elevated leukocytes, elevated protein, and decreased glucose levels.

A 5 year old has a fracture of the right upper arm. The x-ray showed that one side of the bone is bent while the other is broken. This known as a __________ fracture. A. Spiral B. Greenstick C. Oblique D. Transverse

B. Greenstick This is a greenstick fracture. These types of fractures are more common in the pediatric population because their bones tend to be more flexible and the periosteum is stronger than an adult.

The nurse is caring for the client with increased intracranial pressure. The nurse would note which of the following trends in vital signs if the ICP is rising? A. Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure. B. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure. C. Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure. D. Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure.

B. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure. A change in vital signs may be a late sign of increased intracranial pressure. Trends include increasing temperature and blood pressure and decreasing pulse and respirations. Respiratory irregularities also may arise.

A nurse is reviewing the record of a child with increased ICP and notes that the child has exhibited signs of decerebrate posturing. On assessment of the child, the nurse would expect to note which of the following if this type of posturing was present? A. Abnormal flexion of the upper extremities and extension of the lower extremities B. Rigid extension and pronation of the arms and legs C. Rigid pronation of all extremities D. Flaccid paralysis of all extremities

B. Rigid extension and pronation of the arms and legs

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.

What is a late sign of compartment syndrome? A. Paralysis B. Pain C. Parethesia D. Pulselessness

D. Pulselessness

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.