A nurse is assessing a 24-year-old female client.
Drag words from the choices below to fill in each blank in the following sentence.
The client is exhibiting clinical manifestations of
The Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"E"}
The client is exhibiting clinical manifestations of Deep Venous Thrombosis (DVT) and Pulmonary Embolism (PE).
Rationale:
Deep Venous Thrombosis (DVT): Classic signs of DVT include throbbing pain, swelling, warmth, and discoloration in the right calf, which the client has had for three days.
Tenderness and pitting edema (1+) further support venous obstruction.
The client has an elevated D-dimer (1.0 mcg/mL, normal <0.4 mcg/mL), indicating a high likelihood of a thrombotic event. The client is taking a combined hormonal oral contraceptive (CHC), which increases the risk of venous thromboembolism.
Pulmonary Embolism (PE): The client reports shortness of breath for one day, a hallmark symptom of PE. DVT can dislodge and travel to the lungs, causing PE. Although lung sounds are clear and SpO₂ is 94%, PE can present without significant lung abnormalities in early stages.
Incorrect Options:
Peripheral Arterial Disease (PAD) → PAD presents with cool, pale skin, weak pulses, and intermittent claudication, which are not seen here.
Cellulitis → While cellulitis can cause redness and swelling, it is typically associated with fever, warmth, and skin infection, which the client does not have.
Popliteal Venous Aneurysm → This is rare and usually asymptomatic unless a clot forms. The client’s symptoms are more consistent with DVT.
Vasculitis → This involves inflammation of blood vessels, often with fever, rash, and systemic symptoms, which the client lacks.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"E"}
Explanation
The client is exhibiting clinical manifestations of Deep Venous Thrombosis (DVT) and Pulmonary Embolism (PE).
Rationale:
Deep Venous Thrombosis (DVT): Classic signs of DVT include throbbing pain, swelling, warmth, and discoloration in the right calf, which the client has had for three days.
Tenderness and pitting edema (1+) further support venous obstruction.
The client has an elevated D-dimer (1.0 mcg/mL, normal <0.4 mcg/mL), indicating a high likelihood of a thrombotic event. The client is taking a combined hormonal oral contraceptive (CHC), which increases the risk of venous thromboembolism.
Pulmonary Embolism (PE): The client reports shortness of breath for one day, a hallmark symptom of PE. DVT can dislodge and travel to the lungs, causing PE. Although lung sounds are clear and SpO₂ is 94%, PE can present without significant lung abnormalities in early stages.
Incorrect Options:
Peripheral Arterial Disease (PAD) → PAD presents with cool, pale skin, weak pulses, and intermittent claudication, which are not seen here.
Cellulitis → While cellulitis can cause redness and swelling, it is typically associated with fever, warmth, and skin infection, which the client does not have.
Popliteal Venous Aneurysm → This is rare and usually asymptomatic unless a clot forms. The client’s symptoms are more consistent with DVT.
Vasculitis → This involves inflammation of blood vessels, often with fever, rash, and systemic symptoms, which the client lacks.
Correct Answer is []
Explanation
The client presents with chest pain radiating to the left arm, sweating, shortness of breath, and epigastric discomfort, which are classic signs of an acute MI.
ST-elevation on ECG and elevated troponin levels confirm myocardial infarction.
Actions to Take:
Administer Oxygen via nasal cannula 2 L/min: The client’s oxygen saturation is 88%, which is below the normal range. Supplemental oxygen helps improve myocardial oxygenation.
Request a prescription for aspirin 325 mg: Aspirin is a first-line treatment for MI as it prevents further platelet aggregation and reduces the risk of clot progression.
Parameters to Monitor:
Vital signs: Blood pressure, heart rate, and respiratory rate should be closely monitored to assess cardiovascular stability.
Electrocardiogram (ECG) rhythm: Continuous ECG monitoring is essential to detect arrhythmias, ischemic changes, or worsening ST elevation that may indicate ongoing myocardial injury.
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