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 C
Explanation
(A) Limit the client’s visitors to one at a time: While it’s important to maintain a peaceful environment for the client, limiting visitors may not be necessary unless the client’s condition is being negatively affected by too many visitors or if there are restrictions due to infection control.
(B) Avoid touching the client: Touch can be a powerful form of communication, especially when a client is unresponsive. Gentle touch can convey caring and presence, so avoiding touch is not typically recommended unless there’s a specific reason to do so (like if the client is in pain).
(C) Continue to talk to the client as if they are alive: This is the most appropriate answer. Even if a client is unresponsive, they may still be able to hear and understand. Continuing to talk to the client can provide comfort and reassurance.
(D) Whisper when talking in the client’s room: Whispering is not necessary and can even be confusing or distressing for the client. It’s better to speak in a normal, calm, and reassuring voice.
Correct Answer is A
Explanation
A) Atropine:
Atropine is a medication used to increase heart rate. It acts by blocking the parasympathetic nervous system, leading to increased heart rate. It is commonly used to treat bradycardia, which is characterized by a heart rate less than 60 beats per minute. In this scenario, with the client's apical heart rate at 49/min, indicating bradycardia, the nurse should prepare to administer atropine to increase the heart rate.
B) Verapamil:
Verapamil is a calcium channel blocker that can decrease heart rate. It is used to treat various cardiac conditions, but it is not appropriate for a client with bradycardia, as it would further lower the heart rate.
C) Digoxin:
Digoxin is a medication used to treat heart failure and certain arrhythmias, but it does not directly increase heart rate. In fact, it can exacerbate bradycardia in some cases.
D) Carvedilol:
Carvedilol is a beta-blocker that can decrease heart rate. It is used to treat hypertension, heart failure, and other cardiovascular conditions, but it is not appropriate for a client with bradycardia, as it would further lower the heart rate.
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