A nurse is caring for a client with a deep vein thrombosis (DVT). What nursing assessment indicates that an important outcome has been met?
Ambulates with assistance.
Oxygen saturation of 98%.
Pain of 2/10 after medication.
Verbalizing risk factors.
The Correct Answer is B
Choice A rationale
Ambulating with assistance is not an immediate indicator of a positive outcome for a client with a DVT. Ambulation is often contraindicated in the initial stages of treatment to prevent a pulmonary embolism. Therefore, this assessment does not reflect a primary outcome of DVT management, which focuses on preventing complications and resolving the clot.
Choice B rationale
An oxygen saturation of 98% is a critical indicator that the client has not developed a pulmonary embolism, a serious and life-threatening complication of DVT. This outcome demonstrates that the thrombus has not dislodged and traveled to the lungs, obstructing gas exchange. Normal oxygen saturation levels range from 95% to 100%.
Choice C rationale
While pain reduction is an important aspect of care, a pain score of 2/10 after medication is a temporary relief measure and does not represent a definitive outcome for DVT. The primary goal is to prevent a pulmonary embolism and resolve the thrombus, and pain control is a supportive measure in achieving that goal.
Choice D rationale
Verbalizing risk factors indicates that the client has received education, which is an important intervention. However, it is an educational outcome, not a physiological one. It does not provide direct evidence that the DVT is resolving or that the client is free from the most serious complication of the disease, a pulmonary embolism.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
This meal provides carbohydrates and fiber, but it lacks sufficient protein, which is essential for tissue repair and collagen synthesis. Protein intake is crucial for wound healing. A green salad provides vitamins, but the overall meal composition is not optimal for providing the building blocks necessary for skin and tissue regeneration.
Choice B rationale
This dietary choice is excellent for promoting wound healing. Chicken breast provides a high-quality source of protein, which is essential for rebuilding damaged tissue and forming new collagen. Broccoli provides vitamin C, a co-factor in collagen synthesis, while a baked potato offers carbohydrates for energy to fuel the healing process.
Choice C rationale
Vegetable lasagna and green salad provide some vitamins and nutrients, but they are often lower in protein than meat-based options, especially if the lasagna filling is not fortified with high-protein ingredients like cottage cheese. Protein is a critical macronutrient for tissue repair, and the lack of a concentrated source makes this choice suboptimal.
Choice D rationale
This meal is low in essential nutrients. While a hamburger provides some protein, it is often high in saturated fat. The fruit cup and cookie provide simple sugars, which can lead to inflammation and have minimal nutritional value for wound healing. The diet pop offers no nutritional benefit and may contain artificial ingredients that are not beneficial.
Correct Answer is A
Explanation
Choice A rationale
Scabies is caused by the mite Sarcoptes scabiei, which burrows into the stratum corneum of the epidermis to lay eggs. This infestation triggers a hypersensitivity reaction (type IV) in the host, resulting in intense pruritus (itching) due to inflammatory mediators. The itching is often worse at night because mite activity increases with warmth, and the host's body temperature rises under bed covers. The characteristic burrows and vesicles are commonly found in interdigital spaces and the axilla.
Choice B rationale
Pediculosis capitis, or head lice, is an infestation caused by the head louse, Pediculus humanus capitis. This parasite feeds on human blood from the scalp, leading to intense itching (pruritus) primarily on the head. Itching is a result of an allergic reaction to the louse saliva. Unlike scabies, pediculosis does not typically present with a rash in the interdigital spaces or axilla, but rather nits (eggs) and lice on the hair shaft and scalp.
Choice C rationale
Tinea corporis, commonly known as ringworm, is a superficial fungal infection of the skin caused by dermatophytes. It presents as an erythematous, circular, scaling patch with a raised border and central clearing, giving it the characteristic ring-like appearance. While it can cause itching (pruritus), it is a localized infection and does not typically manifest with generalized, nocturnal pruritus in the axilla and between the fingers like scabies.
Choice D rationale
Eczema, or atopic dermatitis, is a chronic inflammatory skin condition characterized by dry, erythematous, pruritic patches. While it causes intense itching, which can be worse at night, the distribution and presentation are different from scabies. Eczema typically affects the flexural areas (e.g., antecubital and popliteal fossae) in adolescents, and does not involve the characteristic burrows or interdigital rash associated with a mite infestation.
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