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A nurse is caring for a client who is experiencing impaired mobility.

Exhibits

Drag words from the choices below to fill in each blank in the following sentence.

The client is at risk for developing

and

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"D"}

A. Diarrhea: Not relevant to the client's condition of impaired mobility and recent hip fracture.

B. Hypocalcemia: Not directly related to the client's current condition and symptoms.

C. Pulmonary embolism: The client is at risk due to limited mobility and signs of deep vein thrombosis.

D. Deep vein thrombosis: The client has symptoms such as a warm, reddened area on the calf, indicating a potential DVT.

E. Hypertension: The client's blood pressure is within normal limits, so this is not a primary concern.


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Related Questions

Correct Answer is B

Explanation

A. Checking the client’s PTT level is unnecessary in this situation because low molecular weight heparin (e.g., enoxaparin) does not typically require PTT monitoring. This test is more relevant for clients receiving unfractionated heparin.

B. Small purple hemorrhagic areas (ecchymosis) at the injection sites are a common and expected side effect of low molecular weight heparin. The nurse should explain to the client that this is a normal reaction to the medication and does not indicate a serious issue.

C. Notifying the healthcare provider immediately is not warranted unless the client shows signs of excessive bleeding, such as hematomas, significant bruising, or a drop in blood pressure. The described ecchymosis is a minor and expected side effect.

D. Assessing the client’s blood pressure and heart rate is a reasonable step if there are concerns about significant bleeding or hemodynamic instability. However, in this case, the described symptoms are localized and do not suggest systemic bleeding.

Correct Answer is D

Explanation

A. A musty odor is not normal and may indicate the presence of infection or moisture inside the cast. The client should report any unusual odors to the healthcare provider.

B. Applying ice to the foot after walking is not typically recommended for a Plaster of Paris cast. The client should focus on elevating the leg to reduce swelling and avoid getting the cast wet.

C. The cast must be kept dry to maintain its integrity. The client should cover the cast with a waterproof covering when showering to prevent damage or weakening of the plaster.

D. Numbness or pain in the toes may indicate impaired circulation or nerve compression, which are serious complications that require immediate medical attention. The client should be instructed to report these symptoms promptly.

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