Global rationale cognitive level analyzing client

Global Rationale:
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 50-4
Question 7
Type: MCSA
A patient wearing a long leg cast has assessment findings of compartment syndrome in the extremity. The nurse
demonstrates understanding of the complication and its specific treatment by gathering which equipment?
1. Pillows to elevate the leg
2. A percussion hammer
3. Buck’s traction equipment
4. Ace bandages
Correct Answer:
Rationale 1 : Elevating the leg above the heart would compromise circulation.
Rationale 2 : At this point the diagnosis has been made; further assessment is not indicated and would waste time.
Rationale 3 : Buck’s traction is not a priority in the current care of this patient.
Rationale 4 : Compartment syndrome occurs when excess pressure in a limited space constricts the structures
within a compartment, reducing circulation to muscles and nerves. With increased edema, this event threatens the
viability of the limb and increases the risk of sepsis. Treatment can include removing the cast entirely or bivalving
it (splitting it apart with a cast cutter) and securing the two sides with Ace wraps, tape, or Velcro straps.
4
Global Rationale:
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 50-4
Question 8
Type: MCSA
A committee of musculoskeletal care nurses has been meeting to formulate policy changes regarding the proper
method for providing pin site care. Based on current research findings, the nurses come to which conclusion?

3
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Reduction of Risk Potential
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 50-4