Question: The nurse is assessing a client who had a fractured femur repaired with an external fixator device. Which assessment findings would cause the nurse concern regarding the development of compartmental syndrome? Select all that apply.
1. Decrease in pulse rate in affected leg
2. Paresthesia distel to area of injury
3. Toes on affected leg cool to touch and edematous
4. Complaints that pins are hurting
5. Complaints of leg pain unrelieved by analgesics or repositioning
6. Client angry and calling loudly to the nurse every 10 minutes
Rationale: The paresthesia, edema, and leg pain unrelieved by analgesics are classic indicators of the development of compartmental syndrome. The decrease in pulse rateis not important; the quality of the pulse is the important observation. The pins usually do not cause undue pain, and frequently, the client is angry regarding the immobility and does not use effective coping measures.
This week’s NCLEX exam practice question came from:
Zerwekh: Illustrated Study Guide for the NCLEX-RN Examination, 7th Edition, Chapter 21, pg 458, question 2
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