what are the expected signs of compartment syndrome

ATI RN

ATI Capstone Medical Surgical Assessment 1 Quizlet

1. What are the expected signs of compartment syndrome?

A. Unrelieved pain, pallor, and pulselessness
B. Fever, swelling, and redness
C. Muscle cramps and weakness
D. Redness and itching

Correct answer: A

Rationale: The correct answer is A: Unrelieved pain, pallor, and pulselessness. Compartment syndrome is characterized by increased pressure within a muscle compartment, leading to inadequate blood supply. This results in severe pain that is unrelieved by rest or medication, pallor due to compromised blood flow, and pulselessness as a late sign of severe ischemia. Choices B, C, and D are incorrect. Fever, swelling, and redness are not typical signs of compartment syndrome. Muscle cramps and weakness may occur due to other conditions, but they are not primary indicators of compartment syndrome. Redness and itching are also not commonly associated with compartment syndrome.

2. A nurse is caring for a client who has a peripherally inserted central catheter (PICC). For which of the following findings should the nurse notify the provider?

A. The dressing was changed 7 days ago
B. The circumference of the client's upper arm has increased by 10%
C. The catheter has not been used in 8 hours
D. The catheter has been flushed with 10 mL of sterile saline after medication use

Correct answer: B

Rationale: An increase in the circumference of the client's upper arm by 10% could indicate deep vein thrombosis, which is a serious condition. Deep vein thrombosis can impede blood flow and potentially lead to life-threatening complications. Therefore, the nurse should notify the provider immediately about this finding. Choice A is not an immediate concern as PICC dressing changes are usually done every 7 days. Choice C is a normal finding as catheters may not be used for certain periods. Choice D is a correct procedure for maintaining catheter patency after medication use.

3. A patient with hypokalemia is being monitored. What should the nurse assess for?

A. Muscle weakness
B. Flattened T waves
C. Checking deep tendon reflexes
D. Seizures

Correct answer: A

Rationale: Corrected Question: A patient with hypokalemia is being monitored. What should the nurse assess for? Corrected Choice A: Muscle weakness Corrected Choice B: Flattened T waves Corrected Choice C: Checking deep tendon reflexes Corrected Choice D: Seizures Rationale: Hypokalemia is associated with muscle weakness due to the effect of low potassium levels on muscle function. Flattened T waves on an ECG are characteristic of hypokalemia but are not a direct assessment for the patient's condition. Checking deep tendon reflexes and seizures are not primary symptoms associated with hypokalemia, making them less relevant for monitoring a patient with this electrolyte imbalance.

4. A healthcare provider is assessing a client who reports a possible exposure to HIV. Which of the following findings should the healthcare provider identify as an early manifestation of HIV infection?

A. Stomatitis
B. Fatigue
C. Wasting syndrome
D. Lipodystrophy

Correct answer: B

Rationale: The correct answer is 'B: Fatigue.' Early manifestations of HIV infection often include symptoms like fatigue, fever, and rash, which are typical of viral infections. Stomatitis (choice A) refers to inflammation of the mouth and lips, which can occur in HIV but is not specific to early infection. Wasting syndrome (choice C) and lipodystrophy (choice D) are more commonly associated with later stages of HIV infection rather than early manifestations.

5. What are the adverse effects of radiation after a mastectomy?

A. S3 heart sound, fatigue
B. Pulselessness in the affected extremity
C. SOB and JVD
D. Localized pain, swelling, erythema

Correct answer: A

Rationale: The correct answer is A: S3 heart sound, fatigue. Radiation after a mastectomy can lead to fatigue and symptoms of heart failure, such as the presence of an S3 heart sound. Choices B, C, and D are incorrect. Pulselessness in the affected extremity would be more relevant to vascular complications, shortness of breath (SOB) and jugular venous distention (JVD) could indicate cardiac or respiratory issues unrelated to radiation, and localized pain, swelling, and erythema are more characteristic of a local inflammatory response rather than the systemic effects of radiation post-mastectomy.