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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A reason: Reducing the risk for infection is important but not the primary goal for DJD as it is not primarily an infectious condition.

Choice B reason: Achieving satisfactory pain control is the primary goal in the management of DJD to improve the client's quality of life and functional ability.

Choice C reason: Obtaining adequate rest and sleep is beneficial for overall health but is secondary to pain control in the management of DJD.

Choice D reason: Improving stress management skills can help with overall well-being but is not the primary focus of care for a client with DJD.

A. Obtain vital signs every 2 hours during hospitalization. B. Encourage deep breathing and coughing exercises. C. Provide an eye shield to be worn while sleeping. D. Teach a family member to administer eye drops.

Correct Answer is C

Explanation

Choice A reason: Obtaining vital signs every 2 hours is standard postoperative care but does not specifically address the needs of a client recovering from retinal detachment surgery.

Choice B reason: While deep breathing and coughing exercises are important postoperative interventions, they are not specific to the care of a client after retinal detachment surgery.

Choice C reason: Providing an eye shield for sleep helps to protect the eye from accidental rubbing or pressure, which is critical after retinal surgery.

Choice D reason: Teaching a family member to administer eye drops is important for ongoing care but is not as immediately critical as protecting the eye from injury.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is C

Explanation

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