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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Respiratory alkalosis, fully compensated: pH is low normal (7.35), and the bicarbonate (HCO3-) level is low (21 mEq/L), indicating metabolic acidosis, not respiratory alkalosis. Respiratory alkalosis would present with a high pH and low PaCO2.
B. Metabolic acidosis, partially compensated: The pH is slightly acidic (7.35), and the bicarbonate level is low (21 mEq/L), indicating metabolic acidosis. The PaCO2 level is normal, suggesting partial compensation by the respiratory system, but the body has not fully compensated for the acidosis yet.
C. Respiratory acidosis, fully compensated: Respiratory acidosis would present with an elevated PaCO2 and a low pH, which is not the case here. The PaCO2 is normal at 40 mmHg, so this option is incorrect.
D. Metabolic acidosis, fully compensated: While the client does have metabolic acidosis, the respiratory system has not fully compensated for the acidosis, as evidenced by the normal PaCO2 level. Therefore, the compensation is partial, not full.
Correct Answer is ["A","C","D"]
Explanation
A. Decreased visual acuity: Decreased visual acuity is a significant factor in head injuries in older adults. Poor vision increases the likelihood of falls and accidents, as individuals are less able to detect obstacles or changes in their environment, leading to an increased risk of injury, including head trauma.
B. Motor vehicle crashes: While motor vehicle accidents can lead to head injuries, they are not as prevalent in older adults compared to other causes such as falls. Older adults are more likely to sustain head injuries from falls rather than from motor vehicle crashes, especially since they may not be as active in driving or are more cautious on the road.
C. Polypharmacy: Polypharmacy, or the use of multiple medications, is a common issue in older adults and can significantly contribute to the risk of falls and head injuries. Certain medications, such as sedatives, antihypertensives, and medications affecting balance or cognition, can increase the risk of dizziness, confusion, and falls, leading to head trauma.
D. Weakness: Muscle weakness, particularly in the lower extremities, is common in older adults and increases the risk of falls. Weakness can impair balance and coordination, making it harder for individuals to prevent falls or recover from them, resulting in head injuries.
E. Chronic hypertension: While chronic hypertension is a risk factor for cardiovascular events such as stroke, it is not a direct cause of head injuries in older adults. Hypertension may contribute to falls indirectly by affecting the ability to maintain balance due to related health complications, but it is not a primary cause of head injuries.
F. Previous military experience: Military experience is not a typical risk factor for head injuries in older adults. Although previous trauma or combat exposure could result in earlier injuries, it is not a common cause of head injuries in older adults compared to other factors like falls, medication use, or weakness.
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