A nurse is caring for a client.
Drag 1 condition and 1 client finding to fill in each blank in the following sentence.
The client is at risk for developing
The Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"A"}
The client is at risk for developing pulmonary embolism due to possible deep vein thrombosis.
Rationale:
The client’s assessment findings strongly indicate the development of a possible deep vein thrombosis (DVT). Key evidence includes unilateral calf swelling (increase from 40 cm to 42 cm), a progressively enlarging reddened area, and recent prolonged immobility from an 8-hour car trip. These findings reflect venous stasis and localized inflammation, which are hallmark features of thrombus formation in the deep veins. The absence of respiratory symptoms and normal breath sounds early in the course further supports that the issue is currently localized to the lower extremity rather than a primary pulmonary condition.
A pulmonary embolism (PE) is a serious and potentially life-threatening complication of DVT. If part of the thrombus dislodges, it can travel through the venous circulation and lodge in the pulmonary arteries, impairing gas exchange and causing sudden cardiopulmonary compromise. Because DVT often precedes PE, early recognition of signs such as unilateral leg swelling and redness is critical for prevention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A.Monitoring blood glucose levels is a metabolic assessment primarily indicated for patients with diabetes mellitus or those receiving parenteral nutrition. Immobility does not directly cause acute fluctuations in serum glucose concentrations in the absence of underlying endocrine pathology. While stress can elevate glucose, it is not a specific indicator of gastrointestinal function or peristaltic efficiency.
B.Vital signs such as heart rate and blood pressure provide critical data regarding the patient's hemodynamic stability and autonomic nervous system response. While significant gastrointestinal distress, such as a bowel perforation or severe obstruction, may eventually cause tachycardia or hypotension, these are late-stage systemic signs. They lack the specificity required to detect early-onset ileus or constipation.
C.Assessing bowel sounds via auscultation is the most direct clinical method for evaluating the mechanical effects of immobility on the digestive tract. Reduced physical activity often leads to decreased peristalsis, potentially resulting in constipation or a paralytic ileus. The presence of hypoactive or absent bowel sounds in all four quadrants specifically alerts the nurse to these common gastrointestinal complications.
D.Oxygen saturation levels reflect the efficiency of pulmonary gas exchange and peripheral tissue perfusion rather than digestive motility. Although severe abdominal distension from an obstruction can secondary impact respiratory excursion by elevating the diaphragm, it is an indirect and non-specific finding. Pulse oximetry is not a diagnostic tool for identifying primary gastrointestinal complications related to a sedentary state.
Correct Answer is A
Explanation
A.Older adults may require extra time for instruction due to age-related changes in processing speed and the potential for sensory deficits. Allowing additional time ensures the client can ask questions and demonstrates the nurse's patience, which reduces anxiety and enhances learning. Rushing the educational process can lead to misunderstandings and poor medication adherence in this population.
B.Providing reading materials in a small font size is inappropriate for older adults who may have presbyopia or other visual impairments. Educational materials should be printed in at least a 14-point font with high contrast to ensure readability. Clear, large text facilitates the client's ability to independently review and follow medication instructions at home without experiencing significant eye strain.
C.Presenting information in lengthy segments can lead to cognitive overload and decreased retention of essential details. Effective teaching for older adults involves "chunking" information into small, manageable pieces that focus on one concept at a time. This allows the client to process and master each step of the medication regimen before moving on to more complex instructions.
D.Using a high tone of voice is often counterproductive because many older adults experience presbycusis, which is the loss of ability to hear high-frequency sounds. A high-pitched voice may sound distorted or muffled to the client. The nurse should use a lower-pitched, clear, and moderately paced speaking voice while facing the client to facilitate better auditory comprehension.
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