A nurse is preparing to care for a client on the medical unit.
Complete the following sentence by using the lists of options. The client is at risk for developing
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}
Correct answers:
1. pulmonary edema
2. shallow rapid breaths
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. An increase in calf size can be a sign of deep-vein thrombosis (DVT), but it is not specific to
DVT and can occur with other conditions such as edema.
B. Capillary refill of 2 seconds is within the expected range and is not indicative of DVT.
C. A palpable cord-like vein is a classic sign of DVT and should be further assessed and reported for appropriate intervention.
D. An extremity feeling cool to the touch can be a sign of impaired circulation but is not specific to DVT and can occur with other vascular conditions.
Correct Answer is B
Explanation
A. Depersonalization is a feeling of detachment from oneself or feeling like one's thoughts, feelings, and actions are not their own. It does not involve perceptual disturbances such as hearing voices.
B. Hallucination is a sensory perception that occurs in the absence of external stimuli. Auditory hallucinations involve hearing voices or sounds that others do not hear, as described by the client in this scenario.
C. Illusion is a misinterpretation of a sensory stimulus that is actually present in the environment. It involves a distortion or misperception of sensory information, not the perception of something that is not there, as in the case of hallucinations.
D. Derealization is a feeling of unreality or detachment from one's surroundings. It involves a distortion in the perception of the external world rather than sensory experiences such as hearing voices.
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