The nurse is evaluating a client for possible deep vein thrombosis (DVT). Which assessment should the nurse perform?

Inspect for distention of peripheral veins

Observe for change in breathing pattern

Palpate the volume of pedal pulses

Assess for inflammation of the calves

Answer and Explanation

The Correct Answer is D

Choice A reason: Inspecting peripheral vein distention assesses superficial thrombosis, not deep vein thrombosis (DVT), which occurs in deep veins like the femoral. DVT presents with calf inflammation, not visible vein distention, making this assessment less specific for diagnosing the condition’s classic signs.

Choice B reason: Observing breathing pattern changes detects pulmonary embolism, a DVT complication, not DVT itself. Calf inflammation is a primary DVT sign, and breathing changes are secondary, making this assessment irrelevant for initial DVT evaluation, focusing on systemic rather than localized findings.

Choice C reason: Palpating pedal pulses assesses arterial flow, not venous thrombosis. DVT causes calf inflammation and swelling, not pulse changes, unless severe. This assessment is less relevant, as DVT primarily affects venous return, making calf inflammation the priority for diagnosis.

Choice D reason: Assessing calf inflammation is critical, as DVT causes unilateral swelling, redness, and warmth due to venous obstruction. This classic sign, often with pain, directly indicates thrombus formation, making it the most specific assessment for diagnosing DVT and guiding anticoagulation therapy.

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Free Nursing Study Resources

Correct Answer is ["A","B","C","D","E"]

Explanation

Choice A reason: Amylase is elevated in acute pancreatitis due to pancreatic acinar cell damage, releasing digestive enzymes. Monitoring serum amylase confirms the diagnosis and tracks disease severity, as levels correlate with inflammation. This is a key marker, essential for assessing pancreatic injury in sudden abdominal pain.

Choice B reason: Glucose levels rise in pancreatitis due to impaired insulin release from damaged pancreatic beta cells. Hyperglycemia indicates disease severity and complications like pancreatic necrosis. Monitoring glucose ensures timely management of metabolic disturbances, critical in acute pancreatitis with sudden pain and systemic effects.

Choice C reason: Serum triglycerides are monitored, as hypertriglyceridemia is a common cause of acute pancreatitis. Elevated levels exacerbate pancreatic inflammation by inducing lipotoxicity. Tracking triglycerides guides treatment, like lipid-lowering therapy, and assesses risk of recurrent attacks, making it essential in suspected pancreatitis cases.

Choice D reason: Calcium levels drop in acute pancreatitis due to fat necrosis binding calcium (saponification). Hypocalcemia signals severe disease and complications like tetany. Monitoring calcium ensures timely supplementation, preventing life-threatening outcomes, and is critical for managing systemic effects in acute pancreatic inflammation.

Choice E reason: White blood cell count rises in pancreatitis due to systemic inflammatory response. Leukocytosis indicates infection or severe inflammation, guiding antibiotic or supportive care needs. Monitoring this assesses disease progression and complications, making it vital for managing suspected acute pancreatitis with abdominal pain.

A. Encourage the client to lie down and rest after meals B. Instruct the client to use antacids only as a last resort C. Teach the client to elevate the head of the bed on blocks D. Remind the client to avoid high fiber foods

Correct Answer is C

Explanation

Choice A reason: Lying down after meals worsens gastroesophageal reflux, as gravity promotes acid backflow into the esophagus. Elevation prevents reflux, and this instruction contradicts evidence-based management, increasing symptoms like heartburn, making it harmful for the client’s condition.

Choice B reason: Using antacids as a last resort is incorrect, as they neutralize acid, relieving reflux symptoms. Antacids are first-line for mild cases, and delaying use may worsen discomfort, making this instruction contrary to standard management of gastroesophageal reflux.

Choice C reason: Elevating the head of the bed on blocks prevents acid reflux by using gravity to keep stomach contents down during sleep. This reduces esophageal irritation, a key strategy in gastroesophageal reflux management, making it the most effective discharge instruction for symptom control.

Choice D reason: Avoiding high-fiber foods is incorrect, as fiber aids digestion and may reduce reflux by promoting gastric emptying. Low-fiber diets can worsen constipation, increasing intra-abdominal pressure, making this instruction detrimental to managing gastroesophageal reflux effectively.

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The nurse is evaluating a client for possible deep vein thrombosis (DVT). Which assessment should the nurse perform?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is admitted with sudden abdominal pain and possible acute pancreatitis. Which serum laboratory test result(s) should the nurse monitor? (Select all that apply)

Correct Answer is ["A","B","C","D","E"]

Explanation

Which instruction should the nurse include in the discharge teaching for a client who has gastroesophageal reflux?

Correct Answer is C

Explanation

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