A nurse is assisting with an in-service about hospital-acquired injuries to a group of staff. Which of the following conditions should the nurse include in the teaching as an example of a hospital-acquired injury?

Deep vein thrombosis

Hypothyroidism

Diabetes mellitus

Hypertension

Answer and Explanation

The Correct Answer is A

A. Deep vein thrombosis (DVT) is a condition characterized by the formation of blood clots in deep veins, commonly occurring in the lower extremities. DVT can be acquired during hospitalization due to factors such as immobility, surgery, or certain medical treatments.
B. Hypothyroidism, diabetes mellitus, and hypertension are chronic medical

conditions that may be managed or exacerbated during hospitalization but are not typically considered hospital-acquired injuries. They are often present before
hospitalization and may require ongoing management during the hospital stay.

C. Diabetes mellitus is a chronic condition characterized by elevated blood sugar levels due to either insufficient insulin production or the body's inability to use
insulin effectively. While diabetes management may be necessary during

hospitalization, it is not considered a hospital-acquired injury. Instead, it is a pre- existing condition that requires ongoing monitoring and treatment.

D. Hypertension, or high blood pressure, is a chronic condition that may require management during hospitalization but is not typically considered a hospital- acquired injury. Hypertension is often managed with medications and lifestyle modifications and may be monitored and treated during the hospital stay.

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Correct Answer is B

Explanation

The client is at risk for developing pulmonary embolism due to possible deep vein thrombosis. The rationale for this answer is based on the clinical findings noted in the nurse's notes. The presence of a reddened area on the client's calf, along with a difference in calf circumference between the left and right legs,suggests the possibility of deep vein thrombosis (DVT). DVT is a condition where a blood clot forms in a deep vein, typically in the legs. This can lead to a pulmonary embolism if a part of the clot breaks off and travels to the lungs, blocking blood flow. The client's recent long-duration car trip could have contributed to the development of DVT, as prolonged immobility is a known risk factor. The client's high fiber diet and adequate fluid intake are more likely to prevent constipation, and there is no indication of lead exposure, breath sounds issues, or atherosclerosis based on the information provided. Therefore, the most appropriate selections are 'pulmonary embolism' for the condition and 'possible deep vein thrombosis' for the client finding.

A. "Advance the cane 12 inches forward when walking." B. "Hold the cane on the side of your affected leg when walking." C. "Keep the cane at the same level as the affected leg when climbing stairs." D. "Move your unaffected leg before your affected leg when walking."

Correct Answer is D

Explanation

A. Advancing the cane 12 inches forward when walking is not a standard instruction for cane use. Typically, the cane is advanced a short distance ahead of the individual's affected leg to provide support and stability during ambulation.
B. Holding the cane on the side of the affected leg does not provide adequate support and stability to the affected side while walking.
C. When climbing stairs, the cane should be held in the hand opposite the affected leg to provide support and balance. Placing the cane at the same level as the affected leg may
lead to imbalance and difficulty ascending stairs safely.

D. This is because when using a cane for ambulation, the cane should be held on the stronger side of the body, and the user should move the cane forward simultaneously with the affected (weaker) leg. Then, the stronger leg is moved forward, which helps in maintaining balance and stability during walking.

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A nurse is assisting with an in-service about hospital-acquired injuries to a group of staff. Which of the following conditions should the nurse include in the teaching as an example of a hospital-acquired injury?

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Correct Answer is B

Explanation

A nurse is reinforcing teaching with a client about using a cane for ambulation. Which of the following statements should the nurse make?

Correct Answer is D

Explanation

A patient begins to fall during ambulation. The nurse would

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