The nurse is evaluating the expected outcomes following thrombolytic therapy for a right leg deep vein thrombosis. Which finding(s) confirms a positive outcome? Select all that apply.
Right extremity comparable in size to left
No bleeding or bruising noted
Right extremity pink
Client denies pain
Pedal pulse thready
Correct Answer : A,C,D
A. Right extremity comparable in size to left: Reduction in swelling indicates improved venous return and resolution of the thrombus. Symmetry between extremities suggests successful clot dissolution and reduced obstruction in the affected vein.
B. No bleeding or bruising noted: While this is a desirable side effect outcome, it is not a direct measure of thrombolytic effectiveness. Thrombolytics carry bleeding risk, but the absence of bruising doesn’t confirm clot resolution.
C. Right extremity pink: A pink, well-perfused extremity suggests adequate blood flow, which reflects successful reperfusion. This indicates improved circulation after clot breakdown and is a positive therapeutic result.
D. Client denies pain: Pain is a hallmark symptom of DVT due to inflammation and obstruction. Decreased or absent pain after thrombolytic therapy reflects clinical improvement and reduced clot burden.
E. Pedal pulse thready: A thready pulse may indicate decreased perfusion and is not a reassuring finding. Effective thrombolytic therapy should lead to strong, palpable pulses if circulation has improved.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "Life is challenging. I take it as it comes.": This statement reflects psychological hardiness — a resilience trait marked by commitment, control, and seeing stress as a challenge rather than a threat. It shows adaptive coping and a proactive mindset in facing life’s difficulties.
B. "I am making it through and just barely holding on.": This response indicates high stress and limited coping capacity. It suggests the person is overwhelmed, which is inconsistent with hardiness, which involves confidence in managing stress.
C. "I am not able to juggle all of the balls of life.": This reflects perceived helplessness and difficulty managing life's demands. It lacks the sense of control and adaptability associated with a hardy personality.
D. "What can you do, it is what it is.": While this may seem like acceptance, it reflects resignation more than resilience. A hardy individual typically views stressors as manageable and worth engaging with, not passively accepted.
Correct Answer is ["A","C","D"]
Explanation
A. Right extremity comparable in size to left: Reduction in swelling indicates improved venous return and resolution of the thrombus. Symmetry between extremities suggests successful clot dissolution and reduced obstruction in the affected vein.
B. No bleeding or bruising noted: While this is a desirable side effect outcome, it is not a direct measure of thrombolytic effectiveness. Thrombolytics carry bleeding risk, but the absence of bruising doesn’t confirm clot resolution.
C. Right extremity pink: A pink, well-perfused extremity suggests adequate blood flow, which reflects successful reperfusion. This indicates improved circulation after clot breakdown and is a positive therapeutic result.
D. Client denies pain: Pain is a hallmark symptom of DVT due to inflammation and obstruction. Decreased or absent pain after thrombolytic therapy reflects clinical improvement and reduced clot burden.
E. Pedal pulse thready: A thready pulse may indicate decreased perfusion and is not a reassuring finding. Effective thrombolytic therapy should lead to strong, palpable pulses if circulation has improved.
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