# Two hours after a lower-leg fracture is immobilized, the client reports escalating pain despite opioid medication. For each finding or action, select the best classification.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=395612&lang=en  
> language: en  
> subject: Potential for Alterations in Body Systems  
> category: ROR

## Question

Two hours after a lower-leg fracture is immobilized, the client reports escalating pain despite opioid medication. For each finding or action, select the best classification.

|  | Concerning acute compartment-syndrome cue | Appropriate urgent action | Unsafe delay or unreliable reassurance |
| --- | --- | --- | --- |
| Escalating pain out of proportion to the injury despite analgesia |  |  |  |
| Marked pain when the nurse passively stretches the toes |  |  |  |
| New paresthesia with tense swelling of the injured lower leg |  |  |  |
| Notify the surgical team urgently, release circumferential dressings per protocol, and perform serial reassessment or pressure measurement if uncertain |  |  |  |
| Wait for absent pulses or paralysis before escalating the findings |  |  |  |
| Assume temporary opioid relief or a present distal pulse rules out the syndrome |  |  |  |

## Explanation

Pain out of proportion, pain with passive stretch, paresthesia, and tense swelling suggest acute compartment syndrome. Escalate immediately, release constrictive dressings per protocol, and reassess serially. Do not wait for absent pulses or paralysis; diagnosis requires urgent surgical review and possible decompression.

## In-depth explanation

Quick answer
Treat escalating disproportionate pain, passive-stretch pain, paresthesia, and tense swelling as acute compartment-syndrome cues. Escalate immediately and begin protocol-directed pressure relief and reassessment.

Why this is correct
Rising pressure within a closed muscle compartment threatens perfusion and tissue viability. Pain patterns and evolving sensory changes can appear before late findings such as paralysis or loss of pulse.

Easy analogy or mental picture
Imagine swelling trapped inside a rigid box. As pressure rises, nerves and vessels are compressed even though a distal pulse may still be present.

Memory hook
Pain out of proportion plus passive-stretch pain: escalate before pulses disappear.

NCLEX decision rule
Notify the surgical team urgently, release circumferential dressings to expose the limb according to protocol, and repeat documented pain and neurovascular assessments. If findings remain inconclusive, seek senior review and pressure measurement; confirmed syndrome requires immediate decompression.

Why the other choices are wrong
Waiting for pulse loss or paralysis relies on late signs. Temporary relief after an opioid does not exclude a pressure emergency, and routine observation can permit irreversible injury.

Source
1British Orthopaedic Association BOASt: Diagnosis and Management of Compartment Syndrome of the Extremities
22026 NCLEX-RN Test Plan

## Clinical scenario

The nurse suspects acute compartment syndrome and compares serial pain and neurovascular findings. The surgical team and facility protocol are immediately available for escalation, dressing release, reassessment, and pressure measurement when the diagnosis remains uncertain.

## Key concepts

- **Acute compartment syndrome** — A limb-threatening rise in pressure within a closed fascial compartment that impairs tissue perfusion.
- **Passive-stretch pain** — Pain produced by stretching muscles within the affected compartment, an important early warning sign.
- **Fasciotomy** — Emergency surgical opening of fascia to decompress an affected compartment and restore tissue perfusion.

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