A nurse is caring for a client who has deep vein thrombosis (DVT) of their right lower leg. Which of the following manifestations should the nurse expect? (Select All that Apply.)

Warmth

Erythema

Swelling

Numbness

Bleeding

Answer and Explanation

Correct Answer : A,B,C

A. Warmth: Warmth over the affected area is a typical sign of DVT. It results from localized inflammation and increased blood flow due to the clot obstructing venous return and irritating the vessel wall.
B. Erythema: Erythema, or redness, often occurs in the area where the thrombus is located. It reflects the inflammatory response triggered by the presence of the clot in the vein.
C. Swelling: Swelling in the affected limb is one of the most common signs of DVT. It results from impaired venous return and fluid buildup due to the obstruction caused by the clot.
D. Numbness: Numbness is not typically associated with DVT. While swelling can sometimes compress nearby nerves and cause discomfort, numbness is not a hallmark feature and would warrant evaluation for other potential causes.
E. Bleeding: Bleeding is not a manifestation of DVT itself. DVT involves clot formation within a vein, not bleeding. However, anticoagulant therapy used to treat DVT can increase the risk of bleeding, but that is a side effect of treatment, not a sign of the condition.

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Correct Answer is B

Explanation

A. The SA node sends an electrical signal greater than 100/min: A fast SA node firing rate may indicate sinus tachycardia, not atrial fibrillation. In atrial fibrillation, the SA node is not the primary pacemaker because disorganized signals originate from multiple ectopic foci in the atria, leading to ineffective atrial contractions.
B. The heart's electrical signals are rapid, chaotic, and irregular: In atrial fibrillation, the atria experience disorganized and chaotic electrical impulses, causing an irregular and often rapid heart rhythm. This results in decreased cardiac output, leading to symptoms like dizziness and palpitations due to poor perfusion.
C. An early electrical signal occurs before the expected sinoatrial (SA) node signal: This describes a premature atrial contraction (PAC), not atrial fibrillation. PACs are isolated early beats and do not typically result in sustained irregular rhythms or significant hemodynamic symptoms like those seen in atrial fibrillation.
D. The heart's electrical transmission through the atrioventricular (AV) node is unusually slow:
Delayed conduction through the AV node is associated with AV blocks, not atrial fibrillation. While AV conduction may be variable in atrial fibrillation, the root problem lies in the atria, not in slowed AV nodal transmission.

A. "You have fewer red blood cells." B. "You have had a gastrointestinal bleed." C. You have a low ferritin level." D. "You have an autoimmune disease.

Correct Answer is A

Explanation

A. "You have fewer red blood cells": Sickle cell anemia results in the production of abnormal hemoglobin, which causes red blood cells to sickle, leading to a reduction in the number of healthy red blood cells. This decreases the oxygen-carrying capacity of the blood, causing fatigue.
B. "You have had a gastrointestinal bleed": Gastrointestinal bleeding can cause anemia, but this is not the primary cause of fatigue in sickle cell anemia. The fatigue is more directly related to the anemia resulting from the sickling of red blood cells.
C. "You have a low ferritin level": Ferritin is a measure of iron storage, and although iron deficiency can lead to fatigue, it is not the primary cause of fatigue in sickle cell anemia. The fatigue is mainly due to the reduced number of red blood cells and their impaired ability to carry oxygen.
D. "You have an autoimmune disease": Sickle cell anemia is a genetic disorder, not an autoimmune disease. The fatigue arises from anemia caused by the sickling of red blood cells, not from an autoimmune process.

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A nurse is caring for a client who has deep vein thrombosis (DVT) of their right lower leg. Which of the following manifestations should the nurse expect? (Select All that Apply.)

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Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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