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 ["B","C","E"]
Explanation
Choice A reason: Include many fresh fruits and vegetables in your diet is not a correct answer, because it may increase the risk of infection for the client with AIDS. Fresh fruits and vegetables may contain bacteria, parasites, or pesticides that can cause gastrointestinal or systemic infections in immunocompromised clients. The nurse should advise the client to wash, peel, or cook fruits and vegetables before eating them, or to avoid them altogether if they have diarrhea or low white blood cell counts.
Choice B reason: Drink at least 2 to 3 L of fluids per day is a correct answer, because it helps prevent dehydration, maintain electrolyte balance, and flush out toxins and waste products. Fluid intake is especially important for clients with AIDS who may experience fever, sweating, vomiting, diarrhea, or oral lesions that can cause fluid loss.
Choice C reason: Eat highcalorie foods is a correct answer, because it helps prevent weight loss, muscle wasting, and malnutrition. Clients with AIDS may have increased caloric needs due to increased metabolic rate, infection, inflammation, or medication side effects. Highcalorie foods can provide energy and support immune function.
Choice D reason: Lower your caloric intake is not a correct answer, because it can worsen the nutritional status and health outcomes of the client with AIDS. Lowering caloric intake can lead to weight loss, muscle wasting, malnutrition, and increased susceptibility to infections and complications. The nurse should encourage the client to meet or exceed their caloric needs based on their weight, activity level, and disease stage.
Choice E reason: Choose foods high in protein is a correct answer, because it helps maintain muscle mass, tissue repair, and immune function. Clients with AIDS may have increased protein needs due to increased protein breakdown, infection, inflammation, or medication side effects. Highprotein foods can provide amino acids and antibodies that are essential for immune response.
Correct Answer is ["A","C","D"]
Explanation
Choice A reason: Sensory perception is one of the six subscales that will be utilized in a Braden Scale assessment, because it measures the degree to which the client can respond to pressurerelated discomfort or pain. Sensory perception can be affected by factors such as level of consciousness, spinal cord injury, or neuropathy. Sensory perception can influence the risk of pressure injuries, as clients with impaired sensory perception may not be able to feel or report the pressure, or change their position to relieve the pressure.
Choice B reason: Age is not one of the six subscales that will be utilized in a Braden Scale assessment, because it is not a direct or independent predictor of pressure injury risk. Age is a demographic variable that can be associated with other factors that affect the risk of pressure injuries, such as skin condition, mobility, or comorbidities. However, age itself is not a factor that is measured or scored in the Braden Scale assessment.
Choice C reason: Friction and shear is one of the six subscales that will be utilized in a Braden Scale assessment, because it measures the degree to which the client's skin is exposed to rubbing or sliding forces. Friction and shear can be affected by factors such as bed linens, transfers, or repositioning. Friction and shear can influence the risk of pressure injuries, as they can damage the skin and underlying tissues, or reduce the blood flow and oxygen delivery to the skin and tissues.
Choice D reason: Nutrition is one of the six subscales that will be utilized in a Braden Scale assessment, because it measures the degree to which the client's intake of food and fluids meets the body's needs. Nutrition can be affected by factors such as appetite, dentition, or swallowing. Nutrition can influence the risk of pressure injuries, as it can affect the skin integrity, wound healing, and immune function of the client.
Choice E reason: Mental state is not one of the six subscales that will be utilized in a Braden Scale assessment, because it is not a direct or independent predictor of pressure injury risk. Mental state is a psychological variable that can be associated with other factors that affect the risk of pressure injuries, such as sensory perception, mobility, or activity. However, mental state itself is not a factor that is measured or scored in the Braden Scale assessment.
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