A nurse is caring for a client who is 12 hr postpartum and has deep-vein thrombosis of the left leg. The client is receiving anticoagulant therapy. Which of the following actions should the nurse take?
Massage the affected extremity every 4 hr.
Initiate bed rest.
Apply an ice pack to the effected extremity for 20 min every 2 hr.
Administer aspirin for pain.
The Correct Answer is B
Deep-vein thrombosis (DVT) is a condition where a blood clot forms in a deep vein, usually in the legs. Bed rest is often recommended for clients with DVT to reduce the risk of the clot dislodging and causing a pulmonary embolism. By minimizing movement and keeping the leg elevated, the nurse can help prevent further complications.
The other options listed are incorrect:
- Massage the affected extremity every 4 hours: Massaging the affected extremity can dislodge the clot, increasing the risk of a pulmonary embolism. It is contraindicated and should not be performed in clients with DVT.
- Apply an ice pack to the affected extremity for 20 minutes every 2 hours: While applying cold compresses or ice packs may be useful in some situations to reduce swelling or pain, it is not recommended for clients with DVT. Heat application or cold application should be avoided because they can promote blood circulation and potentially dislodge the clot.
- Administer aspirin for pain: Aspirin is not typically used for pain management in DVT. Anticoagulant therapy is the primary treatment for DVT, and specific anticoagulant medications are prescribed to prevent further clot formation and reduce the risk of complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The response acknowledges the client's feelings and validates their experience without reinforcing or denying the delusion. It demonstrates empathy and invites further exploration of the client's concerns. Open-ended statements like this can encourage the client to express their thoughts and feelings, allowing for therapeutic communication and building trust between the client and nurse.
"The psychiatric staff is not FBI. They are here to help you." This response directly contradicts the client's belief and may lead to increased distrust or resistance. It is important to avoid directly challenging delusions or imposing one's own reality on the client, as it can escalate their distress.
"What makes you think the staff is following you?" While this response seeks more information, it may inadvertently reinforce or amplify the client's delusion. It could be interpreted as confirmation or validation of their belief, potentially increasing anxiety or paranoia.
"Why do you feel the staff is the FBI?" This response also seeks more information, but it may come across as challenging or dismissive. It could potentially trigger defensiveness or hostility in the client. It is important to approach the client's beliefs with empathy and respect rather than questioning or interrogating them.
Correct Answer is A
Explanation
Explanation
A. Write the information at an 8 th grade reading level
Writing the information at an 8th-grade reading level ensures that it is accessible and understandable to a wide range of individuals in the community. Hypertension is a common health condition, and it is important to provide information in a clear and concise manner that can be easily comprehended by the target audience.
Explaining medical terminology using basic, one-syllable in words in (option B) is not recommendable because it may oversimplify the information and potentially undermine the importance of accuracy and precision in healthcare communication.
Using a 12-point font size in (option C) is not recommendable because it is a general guideline for readability, but it is not the most critical aspect when developing a brochure. The readability of the content itself is more important than the specific font size.
D. Presenting information from complex to simple in (option D) is not recommendable because it is not the most effective approach when developing a brochure about hypertension. It is more beneficial to present information in a simple and straightforward manner from the beginning to enhance understanding and engagement.
Therefore, the nurse should write the information at an 8th-grade reading level (option A) to ensure that it is easily accessible and comprehensible for the target audience.
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