The nursing care plan for a client in traction includes regular assessments for venous thromboembolism. When assessing a client's lower limbs, what sign or symptom is suggestive of deep vein thrombosis (DVT)?
Increased circulation of the calf
Pale-appearing calf
Increased warmth in the calf
Loss of sensation to the calf
Swelling and tenderness of the calf
The Correct Answer is E
Choice A reason: Increased circulation of the calf is not a sign or symptom of DVT, but a normal finding of the blood flow in the leg. It can be assessed by palpating the pulses, checking the capillary refill, or observing the skin color and temperature.
Choice B reason: Pale-appearing calf is not a sign or symptom of DVT, but a sign of arterial insufficiency or ischemia. It indicates the reduced blood supply and oxygen delivery to the tissues, which can cause pain, numbness, or coldness of the leg.
Choice C reason: Increased warmth in the calf is not a specific sign or symptom of DVT, but a possible sign of inflammation or infection. It may be accompanied by redness, swelling, or fever, which can indicate a local or systemic inflammatory response.
Choice D reason: Loss of sensation to the calf is not a sign or symptom of DVT, but a sign of nerve damage or compression. It may be caused by trauma, injury, diabetes, or other conditions that affect the peripheral nervous system.
Choice E reason: Swelling and tenderness of the calf is a common sign or symptom of DVT, as it indicates the presence of a blood clot in the deep veins of the leg. It may also cause pain, cramping, or heaviness of the leg, which can worsen with movement or standing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Calcitriol (Fortica) is not the medication that will have the least effect in increasing the client's bone mass, as it is a synthetic form of vitamin D that helps the body absorb calcium and phosphorus, which are essential for bone health. Calcitriol also regulates the bone remodeling and prevents the bone resorption.
Choice B reason: Calcium (Caltrate) with Vitamin D (Caltria) is not the medication that will have the least effect in increasing the client's bone mass, as it is a combination of calcium and vitamin D that works synergistically to enhance the bone density and strength. Calcium is the main mineral component of the bone, and vitamin D helps the body absorb calcium and phosphorus.
Choice C reason: Alendronate (Fosamax) is not the medication that will have the least effect in increasing the client's bone mass, as it is a bisphosphonate that inhibits the activity of osteoclasts, which are the cells that break down the bone. Alendronate reduces the bone loss and increases the bone mass, and it is used to treat and prevent osteoporosis.
Choice D reason: Calcium (Caltrate) without Vitamin D (Calcio) is the medication that will have the least effect in increasing the client's bone mass, as it is a calcium supplement that does not contain vitamin D, which is necessary for the calcium absorption and utilization. Calcium alone may not be sufficient to prevent or treat osteoporosis, and it may also cause side effects such as constipation, kidney stones, or hypercalcemia.
Choice E reason: None of the above is not a correct choice, as there is one option that matches the medication that will have the least effect in increasing the client's bone mass.
Correct Answer is E
Explanation
Choice A reason: Atopic dermatitis is not a likely explanation for the assessment findings, as it is a chronic inflammatory skin condition that causes itching, scaling, and dryness of the skin, usually on the face, neck, and flexural areas.
Choice B reason: Cellulitis is a possible explanation for the assessment findings, as it is a bacterial infection of the skin and subcutaneous tissues that causes warmth, redness, swelling, and pain of the affected area. However, it is not the most likely explanation, as it usually occurs as a result of a break in the skin, such as a wound, insect bite, or ulcer, which is not mentioned in the scenario.
Choice C reason: Seborrheic keratosis is not a relevant explanation for the assessment findings, as it is a benign skin growth that causes brown, black, or tan lesions that have a waxy or scaly appearance, usually on the face, chest, or back.
Choice D reason: Pemphigus is not a plausible explanation for the assessment findings, as it is a rare autoimmune disorder that causes blisters and erosions of the skin and mucous membranes, usually on the trunk, scalp, or mouth.
Choice E reason: Lymphedema is the most likely explanation for the assessment findings, as it is a condition that causes swelling of the arm due to impaired lymphatic drainage after mastectomy surgery. It can also cause warmth, redness, and tenderness of the affected limb.
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