A client has been involved in an automobile accident and is assessed to have an enlarged spleen. What does the nurse understand is the significance of attempting to prevent unnecessary removal of the spleen for this client?

The spleen is lymphoid tissue in the upper chest that contains stem cells.

The spleen assists with blood clotting.

The spleen is a large lymph node and takes waste debris away.

The spleen is a lymphatic structure and assists with phagocytosis

Answer and Explanation

The Correct Answer is D

A. The spleen is lymphoid tissue in the upper chest that contains stem cells: The spleen is located in the left upper abdomen, not the chest, and it does not house hematopoietic stem cells. While it is lymphoid tissue, it does not primarily contain stem cells; stem cells are mainly found in the bone marrow.
B. The spleen assists with blood clotting: While the spleen stores platelets, its primary function is not clotting. It plays a secondary role in hemostasis but is more essential for filtering blood and immune responses.
C. The spleen is a large lymph node and takes waste debris away: The spleen is not a lymph node, although both are part of the lymphatic system. Lymph nodes filter lymph fluid, while the spleen filters blood. While the spleen does remove waste debris (through phagocytosis), it's not accurate to describe it as a large lymph node.
D. The spleen is a lymphatic structure and assists with phagocytosis: The spleen plays a critical role in immune defense by filtering blood, removing pathogens, and facilitating phagocytosis of old or damaged cells. Preserving it reduces the risk of overwhelming infections.

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Correct Answer is D

Explanation

A. Congenital neural tube defect: This condition affects the central nervous system and is unrelated to the structure or function of the heart valves. It does not contribute to the development of mitral regurgitation.
B. Pacemaker inserted 2 years ago: While a pacemaker reflects a history of cardiac rhythm issues, it does not directly affect the mitral valve. It provides less diagnostic value for assessing structural valve disorders.
C. One-pack-a-day smoker for 20 years: Smoking is a major risk factor for coronary artery disease and other cardiovascular problems like hypertension. While these can indirectly affect the heart, smoking is not a primary cause of mitral valve damage leading to regurgitation.
D. Rheumatic fever: Rheumatic fever is a leading cause of mitral valve damage, often resulting in regurgitation due to scarring and deformation of the valve as a complication of untreated or poorly treated strep throat infection. This history is highly relevant and provides strong diagnostic value.

A. Avoid crossing the legs. B. Massage the calves and thigh. C. Prop pillows under knees. D. Encourage ambulation twice daily.

Correct Answer is A

Explanation

A. Avoid crossing the legs: Crossing the legs can impede venous return by compressing the veins in the leg therefore increasing the risk of clot formation in the lower extremities. Teaching clients to keep legs uncrossed helps maintain proper circulation and reduces venous stasis postoperatively.
B. Massage the calves and thigh: Massaging the legs can dislodge an existing thrombus, leading to a potential pulmonary embolism. This practice is contraindicated in clients at risk for deep vein thrombosis (DVT).
C. Prop pillows under knees: Placing pillows under the knees promotes venous stasis by compressing the popliteal vein. This can increase the risk of thrombophlebitis and should be avoided in post-op care.
D. Encourage ambulation twice daily: Although ambulation is beneficial, twice daily may not be frequent enough to adequately promote circulation. More regular movement and leg exercises are typically recommended to prevent clot formation.

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A client has been involved in an automobile accident and is assessed to have an enlarged spleen. What does the nurse understand is the significance of attempting to prevent unnecessary removal of the spleen for this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

The nurse is teaching a postoperative client measures to reduce the risk of postoperative complications. Which teaching point would the nurse reinforce to decrease the risk of thrombophlebitis and phlebothrombosis?

Correct Answer is A

Explanation

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