A nurse is caring for a client who is postoperative following vascular surgery.
Which of the following manifestations should indicate to the nurse that the client has developed a thrombus?
Dull, aching calf pain.
Positive Kernig's sign.
Soft, pliable calf muscle.
Positive Homan's sign.
None
None
The Correct Answer is A
The correct answer is Choice A: Dull, aching calf pain.
Choice A rationale:
Dull, aching calf pain is a common symptom of deep vein thrombosis (DVT), which can occur postoperatively, especially after vascular surgery. This pain is often due to a blood clot forming in the deep veins of the leg.
Choice B rationale:
Positive Kernig's sign is associated with meningitis and not typically related to thrombus formation.
Choice C rationale:
Soft, pliable calf muscle is not indicative of a thrombus. A thrombus would more likely cause tenderness and swelling.
Choice D rationale:
Positive Homan's sign (pain in the calf upon dorsiflexion of the foot) can be an indicator of DVT, but it is less reliable than dull, aching calf pain.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice D rationale:
The nurse should seek clarification for the prescribed medication Propranolol when caring for a client with an exacerbation of asthma. Propranolol is a non-selective beta-blocker, and its use can exacerbate bronchoconstriction and potentially worsen asthma symptoms. In patients with asthma, non-selective beta-blockers are generally contraindicated. The nurse should consult with the provider to ensure that Propranolol is the appropriate choice, as there may be safer alternatives to manage the client's condition without worsening their asthma.
Choice A rationale:
Prednisone is a corticosteroid commonly used to reduce inflammation and manage asthma exacerbations. It is an appropriate medication for asthma management and does not require clarification.
Choice B rationale:
Montelukast is a leukotriene receptor antagonist that is also used in the management of asthma. It helps to reduce airway inflammation and bronchoconstriction. Montelukast is an appropriate choice for asthma and does not need further clarification.
Choice C rationale:
Aminophylline is a bronchodilator that can be used in the treatment of asthma. While it may have potential side effects and interactions, it is not the first medication that needs clarification in this scenario. Propranolol, due to its potential to worsen asthma symptoms, takes precedence.
Correct Answer is C
Explanation
Choice A rationale:
The nurse should not instruct the client to rest with the legs above heart level. While elevating the legs can be helpful for managing symptoms of peripheral artery disease (PAD), it is not a suitable choice for older adults, especially those with heart conditions. It can put additional strain on the heart and may not be appropriate for all clients. Elevation of the legs should be done with caution and under healthcare provider guidance.
Choice B rationale:
The nurse should not advise the client to wear antiembolic stockings during the day. Antiembolic stockings, also known as compression stockings, are primarily used for venous insufficiency and the prevention of deep vein thrombosis (DVT). They may not be effective or necessary for the management of PAD. It's important to tailor the instructions to the specific condition, and in the case of PAD, other strategies may be more appropriate.
Choice C rationale:
The correct answer is choice C. The nurse should instruct the client to adjust the thermostat so that the environment is warm. This is an important recommendation for clients with PAD because keeping the extremities warm can help improve circulation and reduce symptoms. Cold environments can exacerbate the vasoconstriction associated with PAD, leading to more discomfort. Maintaining a warm environment is a simple and effective measure for symptom management.
Choice D rationale:
The nurse should not recommend applying a heating pad on a low setting to help relieve leg pain. While heat can provide temporary relief for muscle pain, it may not be the best option for clients with PAD. Applying heat directly to the affected area can sometimes lead to burns or skin damage, especially in older adults who may have decreased sensation. Heat should be used cautiously, and other methods like keeping the environment warm are preferred.
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