A nurse is caring for a client who is postoperative. For which of the following findings should the nurse suspect the client is experiencing a deep- vein thrombosis?

Muscle spasms

Absent pedal pulse

Numbness of the affected extremity

Warmth of the affected extremity

Answer and Explanation

The Correct Answer is D

A. Muscle spasms: These are not typically associated with DVT.
B. Absent pedal pulse: This suggests arterial occlusion, not venous thrombosis.
C. Numbness of the affected extremity: Numbness is not a classic sign of DVT and might indicate a nerve-related issue.
D. Warmth of the affected extremity. Warmth is a hallmark sign of DVT due to localized inflammation and impaired venous circulation.

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Correct Answer is D

Explanation

A. "Unable to repeat the names of three common objects the nurse names.": This indicates possible short-term memory issues but is less critical than a reduced level of consciousness.
B. "Unable to answer a judgment question correctly.": Poor judgment is less immediately concerning compared to reduced consciousness.
C. "Unable to remember their adult children's names.": Long-term memory loss is not as urgent as changes in consciousness or neurological status.
D. "Unable to remain fully awake while answering questions.": This finding suggests a potential decline in neurological status, such as increased intracranial pressure or a brain injury, and is the priority.

A. Monitor the client for weight B. Check the client for increased hypopigmentation under the patch. C. Advise the client about increased dry mouth. D. Inform the client of the adverse effect of diarrhea.

Correct Answer is C

Explanation

A. Monitor the client for weight: Clonidine does not typically cause significant weight changes.
B. Check the client for increased hypopigmentation under the patch: Hypopigmentation is not a known side effect of clonidine patches.
C. Advise the client about increased dry mouth. Dry mouth is a common side effect of clonidine due to its central action in reducing sympathetic output.
D. Inform the client of the adverse effect of diarrhea: Clonidine more commonly causes constipation, not diarrhea.

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A nurse is caring for a client who is postoperative. For which of the following findings should the nurse suspect the client is experiencing a deep- vein thrombosis?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in an assisted living facility is collecting data from an older adult client who fell in their room and hit their head on the dresser. Which of the following findings is the nurse's priority?

Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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