An adult female client, who is an office worker, comes to the occupational health dinic with an edematous right leg twice the size of the left leg. The client reports that she is otherwise healthy, smokes 2 packs of cigarettes a day, and takes birth control pills on a regular basis. Which initial nursing action should the occupational health nurse take?
Ask the client to rate her pain on a scale from 0 to 10.
Teach the client to keep the leg elevated
Treat with ice then apply an elastic bandage wrap.
Check the leg for warmth and erythema.
The Correct Answer is D
A. While pain assessment is important, it's not the priority in this situation. Pain can be present in various conditions, and it doesn't necessarily indicate DVT.
B. Elevating the leg can help reduce swelling but is not the initial action. The nurse needs to rule out a serious condition like DVT first.
C. Applying ice and an elastic bandage might be appropriate for some types of swelling but is not the correct initial action for a sudden, unilateral leg swelling.
D. The client presents with sudden, unilateral leg swelling, which is a red flag for deep vein thrombosis (DVT). DVT is a serious condition that can lead to pulmonary embolism. Therefore, the nurse's priority is to assess for signs of inflammation, which are warmth and erythema.
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Related Questions
Correct Answer is B
Explanation
A. This is a valid nursing problem and directly related to the client's condition. However, while fatigue is a significant concern, it is often a symptom of other underlying issues.
B. This is the highest priority nursing problem. Pain is a primary symptom of acute RA exacerbation and significantly impacts the client's quality of life, mobility, and overall well-being. Addressing pain is crucial for immediate comfort and to facilitate other interventions.
C. This is also a valid nursing problem, directly linked to the client's symptoms. However, it is a consequence of the pain, not the primary issue. Addressing the pain will improve mobility.
D. This is a potential long-term concern but not the highest priority at this acute stage. The client's immediate needs related to pain and mobility are more pressing.
Correct Answer is C
Explanation
A. While it's important to monitor for complications, this is not a typical initial instruction for a soft tissue injury.
B. Early range of motion exercises are generally not recommended for acute soft tissue injuries, as they can increase swelling and pain.
C. This is the correct instruction. Applying ice to the injured area helps reduce swelling and pain. It should be applied intermittently to prevent tissue damage from excessive cold.
D. Heat is typically used in the later stages of healing to promote blood flow and relaxation, but continuous heat application can be harmful in the acute phase.
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