A nurse on the postpartum unit is performing a physical assessment of a client who is being admitted with a suspected deep-vein thrombosis (DVT). Which of the following clinical findings should the nurse anticipate the client will exhibit?
Area of warmth
Report of nausea
Cool-to-touch extremity
Calf tenderness when massaged .
The Correct Answer is D
Choice A rationale
While an area of warmth can be a symptom of deep vein thrombosis (DVT), it is not the most specific or indicative symptom. DVT is a condition in which blood clots form in veins located deep inside the body, usually in the thigh or lower legs. The most common symptoms include swelling of the foot, ankle, or leg, usually on one side, cramping of the affected leg, severe leg pain, and skin on the affected area that is warmer than the skin on surrounding areas.
However, these symptoms can also be associated with other conditions, making them less specific for DVT.
Choice B rationale
Nausea is not typically a symptom of deep vein thrombosis (DVT). The most common symptoms of DVT include swelling of the foot, ankle, or leg, usually on one side, cramping of the affected leg, severe leg pain, and skin on the affected area that is warmer than the skin on surrounding areas.
Choice C rationale
A cool-to-touch extremity is not typically a symptom of deep vein thrombosis (DVT). In fact, the skin over the affected area is often warmer than the skin on surrounding areas. Therefore, a cool-to-touch extremity would not typically be expected in a client with suspected DVT.
Choice D rationale
Calf tenderness when massaged is a common clinical finding in clients with deep vein thrombosis (DVT)2. DVT often causes pain and swelling in the affected leg, and this pain can be particularly noticeable or worsen when the calf is massaged or the client is standing or walking. Therefore, calf tenderness when massaged would be a clinical finding that a nurse should anticipate in a client being admitted with a suspected DVT.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
Choice A rationale
Infective endocarditis is an infection of the inner lining of the heart’s chambers or valves. It’s typically caused by bacteria entering the blood and settling in the heart. It is considered an acquired heart disease because it develops during a person’s lifetime.
Choice B rationale
Kawasaki disease is an illness that causes inflammation in arteries, veins, and capillaries. It’s most common in children younger than 5 years old. While it’s not a heart disease, it can lead to serious heart problems if not treated.
Choice C rationale
Hypoplastic left heart syndrome is a type of congenital heart defect, meaning it’s present at birth. Therefore, it’s not considered an acquired heart disease.
Choice D rationale
Cardiomyopathy is a disease of the heart muscle that makes it harder for the heart to pump blood to the rest of the body. It can be acquired or inherited.
Choice E rationale
Transposition of the great vessels is a serious but rare heart defect present at birth (congenital), in which the two main arteries leaving the heart are reversed (transposed). Therefore, it’s not considered an acquired heart disease.
Correct Answer is C
Explanation
Choice A rationale
Terbutaline does not typically cause a decrease in maternal blood glucose levels. It is a medication used to relax the muscles in the uterus to prevent premature labor.
Choice B rationale
Terbutaline does not enhance the production of fetal lung surfactant. It is used to relax the muscles in the uterus to prevent premature labor.
Choice C rationale
Weakened uterine contractions are an expected finding in a client who has received terbutaline. Terbutaline is a tocolytic medication, which means it works to inhibit uterine contractions in order to prevent or halt preterm labor.
Choice D rationale
Terbutaline does not typically cause a decrease in fetal heart rate. It is used to relax the muscles in the uterus to prevent premature labor.
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