A 38-year-old female client was diagnosed with a right lower extremity deep vein thrombosis (DVT) after surgery 2 days ago. This morning the nurse reviews the client's electronic health record to complete a shift assessment. Data from the health record include a prescription from the primary health care provider for warfarin 5 mg orally every day, and the following laboratory results:
- Hemoglobin: 17 g/dL
- Hematocrit: 44.9%
- WBC count: 5500/mm³
- Platelets: 160,000/mm³
- aPTT: 40 sec
- PT: 12 sec
- INR: 0.9
- BUN: 16 mg/dL
- Creatinine: 0.6 mg/dL
The nurse assesses the client for which signs and symptoms of a DVT?
Unilateral edema
Nausea
Groin discomfort
Calf pain
Correct Answer : A,C,D
Choice A reason: Unilateral edema is a common sign of DVT. This occurs due to the obstruction of blood flow in the affected vein, leading to fluid buildup in the tissue, which causes swelling. The swelling is usually confined to the area of the leg where the clot is located, making it an important diagnostic indicator. In DVT, the affected limb often appears swollen compared to the other limb, and this can be easily observed by the healthcare provider during the physical examination.
Choice B reason: Nausea is not typically associated with DVT. While nausea can occur due to various medical conditions, it is not a primary symptom of DVT. DVT primarily affects the circulatory system, leading to symptoms related to impaired blood flow, such as swelling, pain, and redness in the affected limb. Therefore, nausea is unlikely to be directly related to the presence of a blood clot in the deep veins of the leg.
Choice C reason: Groin discomfort can be a symptom of DVT, especially if the clot is located in the femoral vein. The femoral vein runs through the groin area, and a clot in this vein can cause pain and tenderness in the groin. This discomfort is due to the pressure and inflammation caused by the clot obstructing blood flow. Patients may report a dull or aching pain in the groin, which can be exacerbated by movement or pressure.
Choice D reason: Calf pain is a classic symptom of DVT. It often presents as cramping, soreness, or aching in the calf due to the presence of a blood clot in the deep veins of the leg. The pain is caused by the increased pressure and inflammation in the affected vein, which irritates the surrounding tissues. This symptom is a key indicator of DVT and should prompt further evaluation and diagnostic testing, such as an ultrasound, to confirm the presence of a clot.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: While CT or MRI scans can be helpful in identifying structural changes in the brain associated with dementia, such as atrophy or the presence of strokes, they are not sufficient on their own to diagnose dementia. These imaging techniques are often used to rule out other causes of cognitive impairment and to support a clinical diagnosis, but they do not provide a complete picture of a patient's cognitive function.
Choice B reason: Patient history and cognitive assessment are the primary methods for diagnosing dementia. The clinical diagnosis is based on a thorough evaluation of the patient's medical history, including any changes in cognitive function, behavior, and daily living activities. Cognitive assessments, such as the Mini-Mental State Examination (MMSE) or Montreal Cognitive Assessment (MoCA), are used to evaluate memory, attention, language, and other cognitive abilities. These assessments help to determine the presence and severity of cognitive impairment and differentiate dementia from other conditions that may cause similar symptoms.
Choice C reason: A brain biopsy is not a standard procedure for diagnosing dementia. It is an invasive procedure that involves taking a small sample of brain tissue for examination under a microscope. While it can provide definitive information about certain types of dementia, such as Creutzfeldt-Jakob disease, it is rarely used due to its invasiveness and associated risks.
Choice D reason: An electroencephalogram (EEG) is a test that measures electrical activity in the brain. It can be useful in diagnosing certain neurological conditions, such as epilepsy, but it is not typically used to diagnose dementia. EEGs do not provide detailed information about cognitive function or the structural changes in the brain associated with dementia.
Correct Answer is B
Explanation
Choice A reason: Reassessing vital signs in 1 hour is not an immediate action and does not address the patient’s current symptoms of dizziness and unsteady gait, which indicate a potential problem that requires immediate attention. Waiting an hour to reassess may delay necessary interventions that could prevent harm.
Choice B reason: Assisting the patient into a sitting position and notifying the healthcare provider is the most appropriate action. The symptoms of dizziness and unsteady gait, along with a BP of 98/60 mmHg, suggest that the patient may be experiencing orthostatic hypotension or a side effect of Carbidopa-Levodopa. Elevating the patient's position can help prevent falls, and notifying the healthcare provider ensures that the situation is assessed and managed promptly. This action addresses the immediate safety of the patient and facilitates appropriate medical intervention.
Choice C reason: Administering the next dose of Carbidopa-Levodopa early is not recommended without specific orders from the healthcare provider. It could potentially lead to overmedication and worsen the patient’s symptoms or cause adverse effects. Medication administration should always follow the prescribed schedule unless otherwise directed by the healthcare provider.
Choice D reason: Educating the patient about increasing his exercise is important for overall health and mobility but is not an immediate intervention for the acute symptoms of dizziness and unsteady gait. The patient’s current condition requires prompt assessment and intervention rather than education on exercise, which can be addressed later once the immediate issue is managed.
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