A nurse is caring for a client who is postoperative following cardiac surgery. Which of the following manifestations should indicate to the nurse that the client has developed a thrombus?
Positive Kernig's sign
Dull, aching calf pain
Soft, pliable calf muscle
Positive Homan's sign
Correct Answer : B,D
A. Positive Kernig's sign:
Positive Kernig's sign is associated with meningitis, not thrombosis. It is a clinical sign where pain is elicited when the hip is flexed at a 90-degree angle and then the knee is extended. This sign is not relevant for identifying a thrombus.
B. Dull, aching calf pain:
Dull, aching calf pain is a common symptom of deep vein thrombosis (DVT). Pain, swelling, and tenderness in the calf are typical manifestations of a thrombus in the leg veins. This symptom should alert the nurse to the possibility of a thrombus.
C. Soft, pliable calf muscle:
A soft, pliable calf muscle is not indicative of a thrombus. In the case of DVT, the affected leg is usually swollen, firm, and tender. Thus, this manifestation does not suggest the presence of a thrombus.
D. Positive Homan's sign:
Positive Homan's sign is identified when there is pain in the calf upon dorsiflexion of the foot. This sign can be indicative of DVT. Although not highly specific or sensitive, it is one of the traditional signs used to assess for the presence of a thrombus in the leg.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
(A) Evaluating the collected data: This step involves analyzing the data that has been collected during the research process. However, in this scenario, the nurse is in the process of researching data, which suggests that the data collection phase is still ongoing.
(B) Searching for credible sources: This is the most appropriate answer. The nurse is in the process of researching data about best practices for reducing medication errors. This indicates that the nurse is currently searching for credible sources of information, which is a crucial step in the EBP process.
(C) Implementing recommendations: This step involves applying the findings from the research to practice. However, in this scenario, the nurse is still in the research phase, so implementation has not yet occurred.
(D) Identifying a problem: While identifying a problem is an important step in the EBP process, in this scenario, the problem (medication errors on a surgical unit) has already been identified. The nurse is now in the process of researching data, which suggests that the problem identification step has already been completed.
Correct Answer is C
Explanation
A. Cerebral edema:
Cerebral edema is not typically associated with hyperkalemia. It is more commonly seen in conditions such as hyponatremia or cerebral trauma.
B. Hypoactive bowel sounds:
Hypoactive bowel sounds are not typically associated with hyperkalemia. They may occur in conditions such as paralytic ileus or intestinal obstruction.
C. Decreased deep tendon reflexes:
Decreased deep tendon reflexes (hyporeflexia) are a common manifestation of hyperkalemia. High potassium levels can impair neuromuscular function, leading to decreased reflexes.
D. Wheezing:
Wheezing is not typically associated with hyperkalemia. It may occur in conditions such as asthma or chronic obstructive pulmonary disease (COPD).
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