The nurse is reviewing the risk factors for venous disease. Which of these situations best describes a person at highest risk for the development of venous disease?
Older adult taking anticoagulant medication
Person who has been on bed rest for 4 days
Person with a 30-year, 1 pack per day smoking habit
Woman in her second month of pregnancy
The Correct Answer is B
A. Older adult taking anticoagulant medication: Anticoagulants reduce the risk of thrombosis.
B. Person who has been on bed rest for 4 days: Prolonged immobility reduces muscle contraction, leading to decreased venous return and increased risk of venous stasis and DVT.
C. Person with a 30-year smoking habit: Smoking is a risk factor for arterial disease rather than venous disease.
D. Woman in her second month of pregnancy: Pregnancy increases venous pressure but is more significant in the third trimester.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Constipation: This involves hardened stool in the colon, causing localized distention but no free fluid.
B. Splenomegaly: Enlargement of the spleen causes a palpable mass in the left upper quadrant but no free fluid.
C. Distended bladder: This causes suprapubic distension but does not produce a fluid wave.
D. Ascites: A positive fluid wave test indicates free fluid in the abdominal cavity, a hallmark sign of ascites. The test is performed by tapping one side of the abdomen and observing for a wave-like transmission of fluid to the opposite side.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"}}
Explanation
|
New Nurse Statement |
Met |
Not Met |
|
I will confirm the patient's pupil size with the scale on the side of the penlight. |
✅ |
|
|
When putting the penlight at the bridge of the nose, the eyes converge and constrict |
✅ |
|
|
I will check the patient's pupillary reflex by shining a light into their eyes. |
✅ |
|
|
When shining the penlight into the patient's eyes, their pupils should dilate |
✅ |
Rationale:
"I will confirm the patient's pupil size with the scale on the side of the penlight" (Met):
This is a correct use of the penlight to assess pupil size and document findings accurately.
"When putting the penlight at the bridge of the nose, the eyes converge and constrict" (Met):
This statement describes the normal accommodation reflex, where the eyes converge and pupils constrict when focusing on a near object.
"I will check the patient's pupillary reflex by shining a light into their eyes" (Met):
This correctly describes testing for the pupillary light reflex, where the pupil constricts in response to light.
"When shining the penlight into the patient's eyes, their pupils should dilate" (Not Met):
This is incorrect. The pupils should constrict in response to light, not dilate. Dilation occurs in response to low light or sympathetic stimulation.
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