The nurse assessing a client's intravenous catheter site suspects a phlebitis based on which clinical findings?
Warmth and palpable cord along the vein
A raised ecchymotic painful area
Swelling and tenderness at the site
Blanching and coolness of surrounding skin
The Correct Answer is A
A. These are indicative of inflammation within the vein, which is characteristic of phlebitis. Warmth is a common sign of inflammation, and the palpable cord suggests that the vein may be hardened or cord- like due to inflammation and irritation.
B. While this could indicate some form of vascular injury or extravasation, it is not a typical presentation of phlebitis. Phlebitis involves inflammation of the vein, which may cause redness, warmth, and tenderness along the course of the vein, but it typically does not manifest as a raised ecchymotic (bruised) area.
C. Swelling occurs due to inflammation within the vein, and tenderness is often present as a result of the irritation and inflammation. These symptoms are commonly observed in cases of phlebitis but are not specific.
D. These are not typical signs of phlebitis. Blanching (turning white) and coolness of the skin may suggest reduced blood flow to the area, which could occur in cases of ischemia or thrombosis but are not characteristic of phlebitis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
B. This statement demonstrates an understanding of palliative care as a supportive approach focused on optimizing independence and quality of life. Palliative care emphasizes symptom management, psychosocial support, and enhancing functional abilities to enable patients to live as fully and independently as possible, even in the context of a progressive neurologic disease. This statement aligns with the principles of palliative care, which aim to empower patients to make choices and maintain control over their lives.
A. This statement reflects a perception of palliative care as solely placing the responsibility of care on the family. While family support is an essential component of palliative care, it is not the sole responsibility of the family. Palliative care aims to provide comprehensive support to patients with serious illnesses, addressing physical, emotional, social, and spiritual needs. It involves a collaborative approach involving healthcare professionals, patients, and their families to ensure holistic care and quality of life.
C. This statement suggests a misconception about palliative care, equating it with relinquishing control of care decisions to a partner or caregiver. In reality, palliative care emphasizes patient-centered decision-making and supports patients in expressing their preferences, values, and goals of care. While caregivers play an important role in the palliative care team, ultimate decision-making authority rests with the patient, and care plans are tailored to align with the patient's wishes and priorities.
D. This statement reflects a misunderstanding of palliative care as a replacement for disease-specific medical care, such as neurology. Palliative care is not mutually exclusive with disease-focused treatment but rather complements it by addressing the broader physical, emotional, and social needs of patients with serious illnesses, including progressive neurologic diseases. Palliative care can be provided concurrently with disease-specific treatments and involves a multidisciplinary team, which may include specialists like neurologists, to ensure comprehensive care.
Correct Answer is ["A","C","D"]
Explanation
A. This intervention promotes emotional expression and allows the client to verbalize their fears, worries, and uncertainties related to the cancer diagnosis. Encouraging the client to express their feelings fosters a sense of emotional support, validation, and empathy, which are essential for coping with the emotional impact of the diagnosis.
C. Cancer diagnosis and treatment often involve multiple appointments, tests, and treatments, which can be overwhelming for the client. Assisting the client with time management and priorities can help alleviate stress and enhance coping by providing structure, organization, and support in managing the demands of the treatment plan and daily life responsibilities.
D. Involving the client in decision-making and allowing them input into the treatment plan empowers the client and promotes a sense of control and autonomy over their care. Collaborative decision-making enhances the client's engagement, adherence, and satisfaction with the treatment plan, which are essential for successful coping and treatment outcomes.
B. Telling the client what coping skills to use may not be the most effective approach, as it disregards the individuality of the client's coping mechanisms and preferences. Instead, the nurse should explore with the client what coping strategies they have used in the past and provide guidance and support in identifying and implementing effective coping strategies that align with the client's needs and preferences.
E. Providing extensive instructions about the treatment plan and prognosis is important for promoting understanding, informed decision-making, and adherence to the treatment plan. However, the timing and amount of information should be tailored to the client's readiness and preferences. Too much information too soon may overwhelm the client and hinder coping, while inadequate information may lead to uncertainty and anxiety. Therefore, the nurse should provide information in a clear, empathetic, and supportive manner, ensuring that the client's informational needs are met while respecting their emotional readiness.
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