The nurse is completing an admission assessment on an older adult client with dehydration, failure to thrive, and who is immobile. The nurse reports to the healthcare provider that the client's right calf is red and swollen. The nurse should suspect which probable cause of these findings?
Fat emboli.
Deep vein thrombosis.
Infection.
Pulmonary embolism.
The Correct Answer is B
Choice A reason: Fat emboli are typically associated with long bone fractures and not commonly linked with dehydration or immobility.
Choice B reason: Deep vein thrombosis (DVT) is a common condition in immobile patients, and redness and swelling in the calf are classic signs.
Choice C reason: While infection can cause redness and swelling, it is usually accompanied by other signs such as fever, which is not mentioned here.
Choice D reason: Pulmonary embolism is a complication that can arise from DVT but would not be the direct cause of calf redness and swelling.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: While obtaining satisfaction with appearance is an important long-term goal, it is not the first step in treatment. Addressing the behavior itself is crucial before tackling self-image issues.
Choice B reason: Achieving steady weight loss is a goal that will likely result from regulating food portions and other treatment interventions. It is not the initial focus when establishing treatment goals.
Choice C reason: Instituting an exercise plan is part of a comprehensive treatment plan but is secondary to establishing control over eating behaviors.
Choice D reason: Regulating food portions is essential for reducing the frequency and volume of binge eating episodes, which is the immediate concern in binge eating disorder management.
Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"C"}
Explanation
Choice A Reason: Hypoglycemia refers to low blood sugar levels, typically below 70 mg/dL (3.9 mmol/L). The client’s fasting blood glucose level is 122 mg/dL (6.8 mmol/L), which is above the normal range, thus ruling out hypoglycemia.
Choice B Reason: Diabetes mellitus is diagnosed when the fasting blood glucose level is 126 mg/dL (7 mmol/L) or higher on two separate tests1. The client’s level is slightly below this threshold, suggesting that he does not currently have diabetes mellitus but is at risk.
Choice C Reason: Prediabetes is indicated by a fasting blood glucose level of 100 to 125 mg/dL (5.6 to 6.9 mmol/L)1. The client’s level falls within this range, indicating that he has higher than normal blood glucose levels but not high enough to be classified as diabetes, hence prediabetes.
Choice D Reason: Gestational diabetes occurs during pregnancy and is not applicable to this male client.
Option i Reason: Fatty liver disease is not directly indicated by the laboratory results provided and is typically associated with elevated liver enzymes and imaging findings.
Option ii Reason: Occupational factors are not directly related to the fasting blood glucose levels.
Option iii Reason: Lack of insulin production is a characteristic of type 1 diabetes, which is not indicated by the client’s fasting blood glucose level alone.
Option iv Reason: Impaired glucose tolerance is a condition where blood glucose levels are higher than normal but not high enough to be classified as diabetes. It is a characteristic of prediabetes and is indicated by the client’s fasting blood glucose level.
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