A client on bedrest complains of pain and burning in the right calf area. What is the nurse's next action?
Deeply palpate the area for rebound tenderness
Percuss over the area for a change in tone
Compare the circumference to the left calf
Medicate the client for pain and reassess in 60 minutes
The Correct Answer is C
Choice A reason: Deeply palpating the area for rebound tenderness is not the nurse's next action, because it is inappropriate and dangerous. Deeply palpating the area for rebound tenderness is a test that involves applying and releasing pressure on the abdomen, which can elicit pain or discomfort in the presence of peritonitis or appendicitis. Deeply palpating the area for rebound tenderness is not relevant or useful for the client's complaint of pain and burning in the right calf area, which may indicate a deep vein thrombosis (DVT), which is a blood clot in the deep veins of the leg. Deeply palpating the area for rebound tenderness can also worsen the pain, damage the tissues, or dislodge the clot, which can cause pulmonary embolism, which is a lifethreatening condition.
Choice B reason: Percussing over the area for a change in tone is not the nurse's next action, because it is inappropriate and useless. Percussing over the area for a change in tone is a test that involves tapping on the chest or abdomen, which can produce different sounds depending on the density of the underlying organs or tissues. Percussing over the area for a change in tone is not relevant or useful for the client's complaint of pain and burning in the right calf area, which may indicate a deep vein thrombosis (DVT), which is a blood clot in the deep veins of the leg. Percussing over the area for a change in tone can also worsen the pain, damage the tissues, or dislodge the clot, which can cause pulmonary embolism, which is a lifethreatening condition.
Choice C reason: Comparing the circumference to the left calf is the nurse's next action, because it is appropriate and useful. Comparing the circumference to the left calf is a test that involves measuring the size of the leg, which can reveal any swelling or edema in the affected area. Comparing the circumference to the left calf is relevant and useful for the client's complaint of pain and burning in the right calf area, which may indicate a deep vein thrombosis (DVT), which is a blood clot in the deep veins of the leg. Comparing the circumference to the left calf can also help diagnose, monitor, or treat the condition, as a difference of more than 2 cm between the legs can suggest a DVT.
Choice D reason: Medicating the client for pain and reassessing in 60 minutes is not the nurse's next action, because it is inappropriate and delayed. Medicating the client for pain and reassessing in 60 minutes is an intervention that involves giving the client a painkiller and checking the response after an hour. Medicating the client for pain and reassessing in 60 minutes is not relevant or useful for the client's complaint of pain and burning in the right calf area, which may indicate a deep vein thrombosis (DVT), which is a blood clot in the deep veins of the leg. Medicating the client for pain and reassessing in 60 minutes can also mask the symptoms, delay the diagnosis, or miss the opportunity to prevent the complications, such as pulmonary embolism, which is a lifethreatening condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Pulmonary embolism is not the correct answer, because it is a condition that affects the lungs, not the arm. Pulmonary embolism is a blockage of one or more arteries in the lungs by a blood clot, which can cause shortness of breath, chest pain, and coughing up blood.
Choice B reason: Ischial tuberosity is not the correct answer, because it is a bony projection on the pelvis, not the arm. Ischial tuberosity is the part of the pelvis that supports the weight of the body when sitting, and it can be injured by trauma, overuse, or infection.
Choice C reason: Compartment syndrome is the correct answer, because it is a condition that affects the arm, and it matches the symptoms of the client. Compartment syndrome is a serious complication of a traumatic injury, such as a fracture, that causes increased pressure within a closed space of the body, such as the forearm. This pressure can compromise the blood flow and nerve function of the affected area, causing pain, numbness, weakness, and pale skin.
Choice D reason: Broken arm syndrome is not the correct answer, because it is not a real medical condition. Broken arm syndrome is a madeup term that does not describe any specific diagnosis or treatment.
Correct Answer is B
Explanation
Choice A reason: "Tomorrow will be better." is not a statement that demonstrates empathy, but rather one that demonstrates false reassurance or denial. False reassurance or denial is a communication barrier that dismisses or minimizes the client's feelings or concerns, and offers unrealistic or vague promises that may not be fulfilled. False reassurance or denial can make the client feel invalidated, misunderstood, or hopeless.
Choice B reason: "This must be hard news to hear. Tell me more about it." is a statement that demonstrates empathy, which is the ability to understand and share the feelings of another person. Empathy is a communication skill that acknowledges and validates the client's feelings or concerns, and invites the client to express and explore them further. Empathy can make the client feel supported, respected, and empowered.
Choice C reason: "What is your biggest fear about this diagnosis?" is not a statement that demonstrates empathy, but rather one that demonstrates probing or prying. Probing or prying is a communication barrier that asks intrusive or inappropriate questions that may make the client feel uncomfortable, defensive, or threatened. Probing or prying can make the client feel violated, judged, or pressured.
Choice D reason: "I believe you can overcome this because I've seen how strong you are." is not a statement that demonstrates empathy, but rather one that demonstrates stereotyping or labeling. Stereotyping or labeling is a communication barrier that assigns a fixed or generalized characteristic to a person or a situation, without considering the individuality or uniqueness of the person or the situation. Stereotyping or labeling can make the client feel objectified, devalued, or misunderstood.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.