A nurse is assessing a client with a temperature of 38°C (100.4°F) and notes a red, swollen area on the client’s leg. Which condition is the client most likely experiencing?
Cellulitis.
Deep vein thrombosis.
Osteomyelitis.
Gout.
The Correct Answer is A
Choice A rationale
Cellulitis is characterized by a red, swollen, and warm area on the skin, often accompanied by fever. It is a bacterial infection of the skin and underlying tissues.
Choice B rationale
Deep vein thrombosis (DVT) typically presents with swelling, pain, and warmth in the affected leg but not redness and fever as primary symptoms.
Choice C rationale
Osteomyelitis involves infection of the bone, presenting with localized pain, swelling, and fever, but not typically a red, swollen area on the skin.
Choice D rationale
Gout causes joint pain, swelling, and redness, usually in the big toe, but not a red, swollen area on the leg.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Administering antipyretic medication as prescribed is a priority intervention for a client with a body temperature of 38°C (100.4°F). Antipyretics help reduce fever and provide comfort to the patient. They work by inhibiting the production of prostaglandins, which are involved in the fever response.
Choice B rationale
Encouraging fluid intake to prevent dehydration is also important, but it is not the priority intervention. Adequate hydration helps maintain fluid balance and supports the body’s ability to regulate temperature.
Choice C rationale
Monitoring vital signs every 4 hours is essential for assessing the patient’s condition, but it is not an intervention that directly addresses the fever. It helps track the patient’s response to treatment and detect any changes in their condition.
Choice D rationale
Applying a cooling blanket to reduce fever can be effective, but it is typically used when antipyretic medications are not sufficient or contraindicated. Cooling measures help lower body temperature through conduction and evaporation.
Correct Answer is A
Explanation
Choice A rationale
Cerebral ischemia due to an embolus that originates in the left atrium is a common complication of chronic atrial fibrillation (AFib). AFib causes irregular and chaotic electrical signals in the atria, leading to poor blood flow and the formation of blood clots. These clots can travel to the brain, causing a stroke. This is the most acute and severe event associated with chronic AFib.
Choice B rationale
Development of ventricular fibrillation is a life-threatening arrhythmia that can occur in patients with severe heart disease, but it is not a common acute event in chronic AFib.
Ventricular fibrillation involves the ventricles and is characterized by rapid, erratic electrical impulses, leading to ineffective heart contractions and sudden cardiac arrest.
Choice C rationale
Ischemia of the cerebellum due to a ruptured intracranial aneurysm is not directly related to chronic AFib. While AFib increases the risk of stroke, it does not specifically cause aneurysms or cerebellar ischemia. Aneurysms are typically related to other risk factors such as hypertension and vascular abnormalities.
Choice D rationale
Prolonged capillary refill secondary to a complete lack of cardiac output is a sign of severe cardiac dysfunction or shock. While AFib can lead to heart failure and reduced cardiac output, it does not typically cause a complete lack of cardiac output. The most acute event related to AFib is the formation of emboli and subsequent stroke.
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