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)?

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.

Choice A reason: This statement indicates the need for further teaching, as it shows that the client does not understand the possible complication of postherpetic neuralgia, which is a chronic pain condition that can persist for months or years after the rash heals. The nurse should explain to the client that some people may experience this condition and that there are treatments available to manage the pain.

Choice B reason: This statement does not indicate the need for further teaching, as it shows that the client understands the importance of preventing the transmission of the virus to others, especially those who have not had chicken pox or the vaccine. The nurse should reinforce this behavior and remind the client to cover the rash with a dressing and avoid contact with pregnant women, newborns, and immunocompromised people.

Choice C reason: This statement does not indicate the need for further teaching, as it shows that the client knows the etiology of the infection. The nurse should confirm that the client is correct and explain that the virus remains dormant in the nerve cells after the initial infection and can reactivate later in life due to stress, aging, or other factors.

Choice D reason: This statement does not indicate the need for further teaching, as it shows that the client recognizes the prodromal symptom of the infection. The nurse should acknowledge that the client is correct and explain that the pain is caused by the inflammation of the nerve fibers where the virus resides. The nurse should also ask the client about the severity and frequency of the pain and provide appropriate interventions.