The nurse has reviewed the Provider Prescriptions at 1355, Laboratory Results at 1450, and Diagnostic Results at 1525.
Complete the following sentence by using the lists of options.
The client is most likely experiencing
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A","dropdown-group-3":"A"}
Rationale for correct choices
• deep vein thrombosis (DVT): The client displays classic findings of DVT, including unilateral leg swelling, warmth, inflammation, and increased calf circumference. These findings, paired with a sedentary lifestyle and recent trauma to the leg, strongly indicate development of a thrombus in the affected extremity.
• Unequal leg circumference: The right calf measures 45.72 cm while the left measures 40.64 cm, showing significant unilateral swelling. A difference greater than 3 cm is strongly associated with DVT due to venous obstruction and impaired return, causing fluid accumulation and increased limb girth.
• Ultrasound results: The duplex ultrasound shows loss of venous compressibility and a thrombus in the right leg. These findings are diagnostic for DVT, confirming venous obstruction and establishing the cause of the client’s symptoms and leg swelling.
Rationale for incorrect choices
• undiagnosed fracture: A fracture would typically produce severe pain, deformity, or inability to bear weight, none of which are strongly present. The ultrasound confirms thrombosis, and the symptoms align more with venous obstruction than bone injury.
• cellulitis of a leg bone: Cellulitis usually presents with diffuse skin redness, warmth, and often fever. Although the leg is warm and inflamed, the presence of a venous thrombus on ultrasound and significant calf size difference more accurately support DVT rather than an infectious process.
• Difficulty walking: Difficulty walking can occur from many causes, such as arthritis or recent injury, and is not specific enough to confirm DVT. Objective findings like limb circumference and ultrasound imaging better demonstrate the underlying condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C"]
Explanation
Rationale:
A. Insert a large-bore IV catheter: A large-bore (18–20 gauge) IV catheter is required to allow rapid infusion of blood products if needed, minimizing hemolysis and ensuring adequate flow. This is critical for the safety and effectiveness of the transfusion, especially in clients who may be hemodynamically unstable.
B. Witness the client signing a consent for transfusion: Obtaining informed consent ensures the client understands the risks, benefits, and alternatives to the blood transfusion. Witnessing the signature is a legal and ethical requirement to confirm that the client has voluntarily agreed to the procedure.
C. Have a second nurse confirm the information on the blood label: Verification by a second nurse prevents administration errors, such as giving the wrong blood type or unit. This double-check process is essential for patient safety and is standard protocol before starting a transfusion.
D. Flush the transfusion tubing with dextrose 5 in water: Blood products should not be administered through tubing flushed with dextrose solutions because dextrose can cause red blood cell hemolysis. Normal saline is the only appropriate solution for priming and flushing blood administration tubing.
E. Explain to the client that transfusion reactions are not serious: Transfusion reactions can be life-threatening, including hemolytic, allergic, or febrile reactions. Minimizing the seriousness of these risks is inappropriate; the client should be informed about potential complications and instructed to report any symptoms immediately.
Correct Answer is C
Explanation
Rationale:
A. Serum calcium level: Cushing’s disease does not typically cause elevated calcium levels. Calcium levels are usually normal unless there is an underlying bone disorder or concurrent condition affecting calcium metabolism.
B. Lymphocyte count: Cortisol excess in Cushing’s disease suppresses the immune system, leading to lymphopenia rather than an increased lymphocyte count. A decreased lymphocyte count is more consistent with the disease process.
C. Serum glucose level: Elevated cortisol levels increase gluconeogenesis and decrease glucose uptake by cells, resulting in hyperglycemia. Clients with Cushing’s disease often exhibit elevated blood glucose as a direct effect of excess cortisol.
D. Serum potassium level: Cortisol has mineralocorticoid activity, promoting potassium excretion by the kidneys. As a result, clients with Cushing’s disease commonly have hypokalemia rather than increased serum potassium levels.
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