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 A
Explanation
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.
Correct Answer is D
Explanation
Choice A reason: Asking the client to describe the purpose of the medication is not enough to evaluate the teaching-learning process. The client may know the rationale for the medication, but not how to use it correctly.
Choice B reason: Assessing the client's respiratory status at the next scheduled visit is not enough to evaluate the teaching-learning process. The client may have improved or worsened respiratory status due to other factors, not necessarily related to the use of the bronchodilator.
Choice C reason: Asking the client if they understand how to use the bronchodilator is not enough to evaluate the teaching-learning process. The client may say they understand, but not demonstrate the correct technique.
Choice D reason: Directly observing the client using the inhaler to give themselves a dose is the best way to evaluate the teaching-learning process. The nurse can assess the client's ability to use the inhaler correctly, and provide feedback and reinforcement as needed.
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