The nurse is caring for a client with a history of deep vein thrombosis. Which intervention should the nurse include in the care plan?
Encourage early ambulation
Apply warm compresses to the leg
Restrict fluid intake
Elevate the affected leg
The Correct Answer is D
Choice A reason: Early ambulation prevents stasis but is contraindicated in acute deep vein thrombosis, as it risks dislodging the clot, causing pulmonary embolism. Leg elevation reduces swelling and promotes venous return, making it the priority intervention to manage acute DVT safely.
Choice B reason: Warm compresses may increase blood flow but are not standard for deep vein thrombosis, as they risk clot dislodgement. Leg elevation reduces edema and venous pressure, improving circulation without mobilizing the clot, making it the preferred intervention for DVT management.
Choice C reason: Restricting fluid intake is inappropriate, as hydration prevents blood viscosity increases that exacerbate deep vein thrombosis. Leg elevation directly reduces swelling and promotes venous return, addressing the primary issue of venous stasis, making it the priority over fluid restriction.
Choice D reason: Elevating the affected leg reduces edema and venous pressure in deep vein thrombosis by promoting venous return to the heart. This decreases clot propagation risk and alleviates pain, making it a key intervention to manage acute DVT effectively and prevent complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Administering an antacid relieves epigastric pain but is premature without assessing pain characteristics. Pain in peptic ulcer disease may indicate complications like perforation, requiring urgent evaluation. Assessment guides whether antacids or other interventions are appropriate, prioritizing patient safety.
Choice B reason: Assessing pain characteristics (e.g., location, intensity, radiation) is the first step, as epigastric pain in peptic ulcer disease may signal complications like bleeding or perforation. This data guides interventions, ensuring timely management of potentially life-threatening conditions, making it the priority action.
Choice C reason: Checking NSAID use identifies ulcer triggers but is secondary to pain assessment. Pain characteristics determine urgency, as severe or radiating pain may indicate perforation, requiring immediate action. Assessment provides critical data before investigating contributing factors like medication history.
Choice D reason: Obtaining a stool sample for occult blood detects gastrointestinal bleeding but is not the first step. Assessing pain characteristics identifies urgent complications like perforation, guiding whether diagnostic tests or interventions are needed, making pain assessment the initial priority.
Correct Answer is A
Explanation
Choice A reason: Assisting with mobility and safety is critical in multiple sclerosis, as muscle weakness and spasticity increase fall risk. Physical therapy and assistive devices enhance safety, reducing injury risk, making it the priority intervention to maintain independence and prevent complications like fractures.
Choice B reason: A high-sodium diet is inappropriate, as it may exacerbate fluid retention, unrelated to multiple sclerosis. Mobility assistance is the priority, as falls are a significant risk due to neurological deficits, making dietary sodium irrelevant to primary symptom management.
Choice C reason: Restricting physical therapy worsens mobility and spasticity in multiple sclerosis. Assisting with mobility and safety is critical, as it prevents falls and maintains function, making therapy restriction counterproductive, as exercise supports neurological health and independence.
Choice D reason: Promoting bed rest increases muscle atrophy and spasticity in multiple sclerosis. Mobility and safety measures are essential, as they reduce fall risk and maintain function, making bed rest detrimental to managing neurological symptoms and overall patient well-being.
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