A nurse is caring for a client.
Click to highlight the findings that require follow-up. To deselect a finding, click on the finding again.
|
Body system |
Findings |
|
Neurologic |
Client is awake, alert, oriented x3 |
|
Cardiovascular |
Client reports no palpitations, heart rhythm regular. Right lower extremity +2 edema from ankle to below the knee joint. Skin warm and inflamed: +2 pedal pulses present in bilateral extremities |
|
Musculoskeletal |
Client reports no groin pain, has slight limp with weight bearing on the right extremity |
Client is awake, alert, oriented x3
Client reports no palpitations, heart rhythm regular.
Right lower extremity +2 edema from ankle to below the knee joint.
Skin warm and inflamed
has slight limp with weight bearing on the right extremity
The Correct Answer is ["C","D","E"]
Rationale for correct choices
• Right lower extremity +2 edema from ankle to below knee: This level of edema in one limb suggests impaired venous return and is a key indicator of possible deep vein thrombosis. Unilateral swelling that develops with reduced mobility places the client at higher risk and warrants immediate assessment. Early detection is important to prevent progression to pulmonary embolism.
• Skin warm and inflamed on right lower extremity: Localized warmth and inflammation are hallmark findings of venous thrombosis or inflammatory processes in the limb. The client’s sedentary pattern and unilateral symptoms strengthen the suspicion of a vascular complication. Prompt evaluation helps guide diagnostic testing such as Doppler ultrasound.
• Slight limp with weight bearing on right extremity: A new limp combined with swelling and inflammation suggests evolving pain or functional impairment. This may indicate deep venous obstruction, localized inflammation, or injury exacerbated by reduced mobility.
Rationale for incorrect choices
• Client is awake, alert, oriented x3: This indicates intact neurological status and does not require follow-up at this time. The client shows no evidence of cognitive changes, syncope, or neurological compromise.
• Client reports no palpitations, heart rhythm regular: A regular heart rhythm without palpitations suggests stable cardiovascular status. There are no immediate arrhythmia-related concerns requiring follow-up.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. Calcium: While calcium is important for many bodily functions, it is not a primary indicator for monitoring hepatic encephalopathy. Calcium imbalances do not directly correlate with the severity or management of this condition.
B. Potassium: Potassium levels are important for overall electrolyte balance, but they are not specific to hepatic encephalopathy. Monitoring potassium is part of routine care but does not indicate the progression or severity of encephalopathy.
C. Ammonia: Elevated ammonia levels are a key contributor to hepatic encephalopathy. The liver normally converts ammonia to urea, and when liver function is impaired, ammonia accumulates, affecting neurological function. Monitoring ammonia helps assess severity and guide treatment interventions.
D. Glucose: While glucose monitoring is important in general care, it is not specific to hepatic encephalopathy. Hyper- or hypoglycemia may occur with liver disease but does not directly reflect the presence or progression of encephalopathy.
Correct Answer is D
Explanation
Rationale:
A. Abdomen: The abdominal skin may be loose due to age-related changes, weight fluctuations, or prior pregnancies, making it less reliable for assessing dehydration in older adults. Lifting skin here may give a false impression of skin turgor.
B. Shoulder: Skin over the shoulder can be affected by aging, sun exposure, or decreased subcutaneous tissue, which can distort the assessment of hydration status. It is not the preferred site for older adults.
C. Neck: The skin of the neck is thin and may show wrinkles or sagging unrelated to hydration. Assessing turgor here is less accurate in older clients and may overestimate skin elasticity changes due to aging.
D. Sternum: The skin over the sternum is relatively less affected by age-related changes and provides a more reliable site for assessing turgor in older adults. Lifting this area allows the nurse to evaluate hydration status more accurately without interference from natural skin laxity elsewhere.
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