Which clinical manifestation should the nurse anticipate as an expected finding for a client diagnosed with deep vein thrombosis (DVT)?
Widespread edema of the affected extremity.
Small area of redness of the affected extremity.
Cool, mottled affected extremity.
Positive bilateral peripheral pulses.
The Correct Answer is A
Choice A rationale
Deep vein thrombosis (DVT) is a condition characterized by the formation of a blood clot in a deep vein, usually in the leg. One of the most common symptoms of DVT is swelling of the affected extremity. This occurs because the blood clot obstructs the flow of blood, causing fluid to build up in the tissues.
Choice B rationale
While redness can be a symptom of DVT, it is not typically confined to a small area. Instead, redness associated with DVT is usually more widespread and is often accompanied by other symptoms such as swelling and pain.
Choice C rationale
A cool, mottled extremity is not a typical symptom of DVT34. DVT usually causes the affected area to feel warmer than the surrounding areas due to inflammation caused by the blood clot.
Choice D rationale
The presence of bilateral peripheral pulses is not a specific finding for DVT34. In fact, the presence of strong peripheral pulses may suggest that blood flow is not significantly obstructed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
The client diagnosed with peripheral arterial disease has impaired tissue integrity related to ischemic tissue of the legs and feet. This condition is often caused by factors such as physical trauma, thermal factors, chemical injury, infection, nutritional imbalances, fluid imbalances, and altered circulation. The most appropriate outcome to include in the care plan would be for the client to verbalize an understanding of appropriate foot care measures by discharge. This is because maintaining skin integrity and providing effective wound care are crucial aspects of managing this condition. By understanding and implementing appropriate foot care measures, the client can help prevent further tissue damage, promote healing, and improve their overall quality of life.
Choice B rationale
While taking anti-platelet medications can be an important part of managing peripheral arterial disease, it may not directly address the nursing problem of impaired tissue integrity. Anti-platelet medications can help prevent blood clots and improve blood flow, but they do not directly promote wound healing or tissue regeneration.
Choice C rationale
Discussing exercises that promote healing of wounds can be beneficial for the client. However, it’s important to note that exercises should be appropriate for the client’s condition and overall health status. Overexertion or inappropriate exercises could potentially exacerbate the condition and further impair tissue integrity.
Choice D rationale
Recognizing the need for an amputation in the near future can be a realistic outcome for some clients with severe peripheral arterial disease. However, this is typically considered a last resort when all other treatment options have failed. It’s also a drastic measure that can significantly impact the client’s quality of life.
Correct Answer is C
No explanation
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