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 C
Explanation
Choice A reason: While obtaining a urine specimen is important for diagnosing infection, it does not address the immediate discomfort and potential urinary retention the client may be experiencing.
Choice B reason: Cleansing the glans penis is part of good hygiene but does not address the client's symptoms of a full bladder and weak urine flow.
Choice C reason: Palpating for suprapubic distention can provide immediate information about bladder fullness and potential urinary retention, which may require prompt intervention.
Choice D reason: Maintaining a voiding diary is useful for tracking symptoms over time but does not provide an immediate assessment or intervention for the client's current symptoms.
Correct Answer is A
Explanation
Choice A reason: Symptoms of heartburn and pain relieved by eating can indeed be consistent with an ulcer, and a complete physical exam can help diagnose the condition and rule out other causes.
Choice B reason: While immediate medical evaluation is important, it is not specified that the symptoms are severe or life-threatening, so it may not be the best initial advice.
Choice C reason: Diet changes can help manage symptoms of heartburn and indigestion, but they may not be sufficient if an ulcer is present.
Choice D reason: It is incorrect to assure the client that the symptoms are only reflux, as ulcer pain can indeed be relieved by food, contrary to the statement.
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