A nurse is assessing a patient diagnosed with deep-vein thrombosis. Which clinical manifestation is consistent with the diagnosis?

Loss of hair over toes.

Tenderness in the thigh.

Rest pain.

Auscultation of bruit over pedal pulse.

Answer and Explanation

The Correct Answer is B

A. Loss of hair over toes:
Loss of hair over the toes is not typically associated with deep vein thrombosis (DVT). Instead, it may be indicative of peripheral arterial disease (PAD) or poor peripheral circulation. In DVT, symptoms are more related to venous congestion and inflammation rather than hair loss.

B. Tenderness in the thigh:
Tenderness in the thigh is a common clinical manifestation of deep vein thrombosis (DVT). It occurs due to the presence of a thrombus within the deep veins of the thigh, causing local inflammation and irritation of the vessel wall. This tenderness may be elicited by palpation along the course of the affected vein.

C. Rest pain:
Rest pain is not typically associated with deep vein thrombosis (DVT). Rest pain is more commonly seen in conditions such as peripheral arterial disease (PAD), where inadequate blood supply to the extremities leads to ischemic pain at rest, especially during periods of reduced blood flow.

D. Auscultation of bruit over pedal pulse:
Auscultation of a bruit over the pedal pulse is not typically associated with deep vein thrombosis (DVT). A bruit is an abnormal sound caused by turbulent blood flow through a narrowed or obstructed vessel, commonly heard in arterial conditions such as atherosclerosis. In DVT, venous obstruction does not typically produce bruits.

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Correct Answer is A

Explanation

A. Using appropriate personal protective equipment (PPE): Standard precautions include the use of PPE such as gloves, masks, gowns, and eye protection when caring for all patients, regardless of their known or suspected infectious status. This helps prevent the transmission of pathogens between the patient and the healthcare provider.

B. Placing patient in positive pressure isolation room: Placing a patient in a positive pressure isolation room is not a component of standard precautions. Positive pressure rooms are typically used for patients with compromised immune systems to protect them from exposure to airborne pathogens. Standard precautions should be followed regardless of the patient's room type.

C. Placing patient in contact precautions: Contact precautions involve specific measures to prevent the transmission of pathogens through direct or indirect contact with the patient or their environment. While contact precautions may be necessary for certain infectious diseases, they are not a component of standard precautions.

D. Wearing gloves at all times: While wearing gloves is part of standard precautions, it is not the only key element. Standard precautions also include other forms of PPE such as masks, gowns, and eye protection, as well as other infection control practices such as hand hygiene and environmental cleaning.

A. Chest pain that radiates to the jaw B. Sudden and severe abdominal pain C. Blurred vision D. Dry cough

Correct Answer is A

Explanation

A. Chest pain that radiates to the jaw:
This finding suggests myocardial ischemia, as chest pain (angina) that radiates to the jaw is a classic symptom of cardiac origin. It is known as referred pain and occurs because the nerves that innervate the heart and jaw have a similar sensory pathway. The pain may be described as pressure, squeezing, or tightness in the chest, and it often spreads to the neck, shoulders, arms, or jaw. This pattern of pain radiation is typical in myocardial ischemia or heart attack due to inadequate blood supply to the heart muscle.

B. Sudden and severe abdominal pain:
While abdominal pain can be associated with various conditions, sudden and severe abdominal pain is not a typical symptom of myocardial ischemia. Instead, it may indicate other abdominal issues such as gastrointestinal problems, pancreatitis, or intra-abdominal vascular events. Myocardial ischemia typically presents with chest pain or discomfort, rather than abdominal pain.

C. Blurred vision:
Blurred vision is not a typical symptom of myocardial ischemia. It may suggest ocular issues such as refractive errors, dry eyes, or conditions affecting the retina or optic nerve. Myocardial ischemia primarily manifests with symptoms related to the heart, such as chest pain, shortness of breath, or other signs of cardiovascular compromise.

D. Dry cough:
A dry cough is not a typical symptom of myocardial ischemia. It may be associated with various respiratory conditions such as allergies, asthma, or respiratory infections. Myocardial ischemia primarily presents with symptoms related to the heart and cardiovascular system, such as chest pain, palpitations, or dyspnea.

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