A nurse is assessing a 24-year-old female client.
Peripheral arterial disease
Deep vein thrombosis
Cellulitis
Pulmonary embolism
Popliteal venous aneurysm
Vasculitis
Correct Answer : B,D
Rationale:
A. Peripheral arterial disease is characterized by diminished pulses, cool extremities, and intermittent claudication, which does not match the client’s findings.
B. Deep vein thrombosis (DVT) is supported by throbbing pain, swelling, discoloration, and warmth in the right calf, all classic signs of a venous clot.
C. Cellulitis presents with localized infection, redness, warmth, and tenderness, but does not explain shortness of breath.
D. Pulmonary embolism (PE) is suggested by the client’s shortness of breath in the context of DVT, indicating possible clot migration to the lungs.
E. Popliteal venous aneurysm is a rare vascular condition and is not consistent with this presentation.
F. Vasculitis involves systemic vessel inflammation, which is not indicated in this case.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Weigh the client daily: Daily weights are essential in Addison’s disease because sudden weight loss may indicate dehydration, and rapid weight gain may signal fluid retention from corticosteroid therapy. Monitoring weight closely helps detect imbalances early and prevent Addisonian crisis.
B. Provide a low-carbohydrate diet: Clients with Addison’s disease require adequate carbohydrate intake since cortisol deficiency impairs glucose regulation. A low-carbohydrate diet could worsen hypoglycemia risk and is not recommended.
C. Administer oral corticosteroids: During an Addisonian crisis, the client requires immediate IV corticosteroids, not oral. Oral medications are insufficient in emergencies because absorption is too slow to stabilize the client.
D. Restrict fluid intake: Fluid restriction would worsen dehydration, which is already a major concern in Addisonian crisis due to sodium loss and volume depletion. Instead, fluids and electrolytes must be carefully replaced to stabilize the client.
Correct Answer is C
Explanation
Rationale:
A. Free T4: In primary hypothyroidism, free T4 levels are typically decreased because the thyroid gland is underactive and not producing sufficient thyroid hormone. An elevation of free T4 would not be expected in this condition.
B. Serum T4: Total serum T4 is also decreased in primary hypothyroidism for the same reason as free T4. The thyroid gland cannot produce enough hormone, so serum T4 levels fall rather than rise.
C. Thyroid stimulating hormone (TSH): In primary hypothyroidism, the thyroid gland fails to produce adequate thyroid hormones. The pituitary gland responds by increasing secretion of TSH in an attempt to stimulate the thyroid, making elevated TSH the expected finding.
D. Serum T3: Serum T3 levels are usually low or normal in hypothyroidism but not elevated. Because T3 is converted from T4, when T4 production drops, T3 levels also generally decrease over time.
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