A nurse is collecting data from a client who requires bed rest and has developed thrombophlebitis. Which of the following findings should the nurse expect when examining the client's leg?

Cool skin

Numbness

Edema

Pallor

Answer and Explanation

The Correct Answer is C

A. Cool skin: Cool skin is not typically associated with thrombophlebitis. It is more common with arterial issues rather than venous problems.

B. Numbness: Numbness is generally a sign of nerve involvement or arterial occlusion, not a classic finding of thrombophlebitis, which primarily affects veins.

C. Edema: Edema is a common finding with thrombophlebitis due to venous inflammation and obstruction of blood flow, which leads to fluid accumulation in the affected limb.

D. Pallor: Pallor is more commonly associated with arterial insufficiency rather than venous issues like thrombophlebitis. Thrombophlebitis often presents with redness and warmth instead of pallor.

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Correct Answer is C

Explanation

A. Obtain platelet aggregation studies to confirm DVT. Platelet aggregation studies are not used to diagnose deep vein thrombosis (DVT). They are more relevant for evaluating platelet function and clotting disorders.

B. Schedule deep tissue massage with physical therapy. Deep tissue massage is contraindicated in clients suspected of having DVT, as it could dislodge the clot and cause a pulmonary embolism or other complications.

C. Arrange for a venous duplex ultrasound. A venous duplex ultrasound is the standard diagnostic test used to confirm DVT. It visualizes the veins and assesses blood flow, helping to detect the presence of a clot.

D. Monitor Homan's sign. Homan’s sign (pain in the calf with dorsiflexion of the foot) was once considered a diagnostic indicator of DVT, but it is no longer considered reliable due to its low sensitivity and specificity. Therefore, it is not routinely used for DVT diagnosis.

A. Soft, pliable calf muscle B. Cool and clammy skin C. Dull, aching calf pain D. Temperature > 100 F

Correct Answer is C

Explanation

A. Soft, pliable calf muscle: A soft and pliable calf muscle is not indicative of a thrombus. Typically, a thrombus leads to swelling and firmness in the affected area.

B. Cool and clammy skin: Cool and clammy skin could indicate poor circulation, but it is not specific to a thrombus.

C. Dull, aching calf pain: Dull, aching calf pain is a key symptom of deep vein thrombosis (DVT) and should prompt further investigation.

D. Temperature > 100°F: A fever could indicate an infection but is not a classic sign of a thrombus.

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A nurse is collecting data from a client who requires bed rest and has developed thrombophlebitis. Which of the following findings should the nurse expect when examining the client's leg?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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