Upon assessment of a newly admitted client, the nurse finds warmth, redness, edema, and tenderness to the left arm following mastectomy surgery 2 weeks ago. What might these assessment findings indicate?
Atopic dermatitis
Cellulitis
Seborrheic keratosis
Pemphigus
Lymphedema
The Correct Answer is E
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Fat embolism is not a likely complication of a leg cast, but a possible complication of a long bone fracture or a joint replacement surgery. It refers to the obstruction of the blood vessels by fat globules that are released from the bone marrow or adipose tissue. It can cause respiratory distress, neurological impairment, or skin petechiae.
Choice B reason: Subcutaneous emphysema is not a common complication of a leg cast, but a rare complication of a chest trauma or a lung disease. It refers to the presence of air or gas in the subcutaneous tissue, which can cause swelling, crepitus, or pain in the affected area.
Choice C reason: Disuse syndrome is not an acute complication of a leg cast, but a chronic complication of prolonged immobility or inactivity. It refers to the deterioration of the body systems due to the lack of physical stimulation. It can cause muscle atrophy, joint stiffness, osteoporosis, or metabolic changes.
Choice D reason: Compartment syndrome is the most likely complication of a leg cast, as it indicates the increased pressure within the muscle compartments of the leg due to the swelling, bleeding, or inflammation. It can cause severe pain, pallor, paresthesia, paralysis, or pulselessness of the affected limb. It is a medical emergency that requires prompt intervention to prevent tissue necrosis or limb loss.
Choice E reason: None of the above is not a correct choice, as there is one option that matches the complication of a leg cast.
Correct Answer is A
Explanation
Choice A reason: A 24-gauge catheter is appropriate for a small and fragile vein of a 12-month-old infant. It minimizes the risk of damaging the vein and ensures the comfort of the infant during IV therapy.
Choice B reason: Starting an IV in the infant's foot is not the first choice due to the risk of movement dislodging the catheter. The hand or the antecubital fossa are preferred sites for IV insertion in infants.
Choice C reason: While it is important to cover the IV insertion site, an opaque dressing is not necessary. A transparent dressing is preferred as it allows for continuous visibility of the site for signs of infection or phlebitis.
Choice D reason: The IV site should not be routinely changed every 3 days. It should be changed based on clinical indications such as signs of infection, infiltration, or phlebitis, or if the IV becomes dislodged.
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