A client on bedrest complains of pain and burning in the right calf area. What is the nurse's next action?
Deeply palpate the area for rebound tenderness
Percuss over the area for a change in tone
Compare the circumference to the left calf
Medicate the client for pain and reassess in 60 minutes
The Correct Answer is C
Choice A reason: Deeply palpating the area for rebound tenderness is not the nurse's next action, because it is inappropriate and dangerous. Deeply palpating the area for rebound tenderness is a test that involves applying and releasing pressure on the abdomen, which can elicit pain or discomfort in the presence of peritonitis or appendicitis. Deeply palpating the area for rebound tenderness is not relevant or useful for the client's complaint of pain and burning in the right calf area, which may indicate a deep vein thrombosis (DVT), which is a blood clot in the deep veins of the leg. Deeply palpating the area for rebound tenderness can also worsen the pain, damage the tissues, or dislodge the clot, which can cause pulmonary embolism, which is a lifethreatening condition.
Choice B reason: Percussing over the area for a change in tone is not the nurse's next action, because it is inappropriate and useless. Percussing over the area for a change in tone is a test that involves tapping on the chest or abdomen, which can produce different sounds depending on the density of the underlying organs or tissues. Percussing over the area for a change in tone is not relevant or useful for the client's complaint of pain and burning in the right calf area, which may indicate a deep vein thrombosis (DVT), which is a blood clot in the deep veins of the leg. Percussing over the area for a change in tone can also worsen the pain, damage the tissues, or dislodge the clot, which can cause pulmonary embolism, which is a lifethreatening condition.
Choice C reason: Comparing the circumference to the left calf is the nurse's next action, because it is appropriate and useful. Comparing the circumference to the left calf is a test that involves measuring the size of the leg, which can reveal any swelling or edema in the affected area. Comparing the circumference to the left calf is relevant and useful for the client's complaint of pain and burning in the right calf area, which may indicate a deep vein thrombosis (DVT), which is a blood clot in the deep veins of the leg. Comparing the circumference to the left calf can also help diagnose, monitor, or treat the condition, as a difference of more than 2 cm between the legs can suggest a DVT.
Choice D reason: Medicating the client for pain and reassessing in 60 minutes is not the nurse's next action, because it is inappropriate and delayed. Medicating the client for pain and reassessing in 60 minutes is an intervention that involves giving the client a painkiller and checking the response after an hour. Medicating the client for pain and reassessing in 60 minutes is not relevant or useful for the client's complaint of pain and burning in the right calf area, which may indicate a deep vein thrombosis (DVT), which is a blood clot in the deep veins of the leg. Medicating the client for pain and reassessing in 60 minutes can also mask the symptoms, delay the diagnosis, or miss the opportunity to prevent the complications, such as pulmonary embolism, which is a lifethreatening condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Capillary refill is not the nurse's priority assessment for this client, because it is not the most relevant and sensitive indicator of the client's condition. Capillary refill is a test that measures the time it takes for the color to return to the nail bed after applying pressure, which reflects the peripheral circulation and tissue perfusion. Capillary refill can be affected by factors such as temperature, hydration, or vasoconstriction. Capillary refill is not a specific or reliable sign of PCP, which is a type of pneumonia caused by a fungus that affects the lungs and respiratory system.
Choice B reason: Radial pulses are not the nurse's priority assessment for this client, because they are not the most relevant and sensitive indicator of the client's condition. Radial pulses are the beats that can be felt at the wrist, which reflect the heart rate and rhythm. Radial pulses can be affected by factors such as activity, emotion, or medication. Radial pulses are not a specific or reliable sign of PCP, which is a type of pneumonia caused by a fungus that affects the lungs and respiratory system.
Choice C reason: Lung sounds are the nurse's priority assessment for this client, because they are the most relevant and sensitive indicator of the client's condition. Lung sounds are the noises that can be heard with a stethoscope over the chest, which reflect the air movement and ventilation in the lungs and airways. Lung sounds can reveal the presence of abnormalities, such as crackles, wheezes, or diminished breath sounds, which indicate fluid, inflammation, or obstruction in the lungs or airways. Lung sounds are a specific and reliable sign of PCP, which is a type of pneumonia caused by a fungus that affects the lungs and respiratory system.
Choice D reason: Skin turgor is not the nurse's priority assessment for this client, because it is not the most relevant and sensitive indicator of the client's condition. Skin turgor is a test that measures the elasticity of the skin, which reflects the hydration and fluid status of the body. Skin turgor can be affected by factors such as age, weight loss, or edema. Skin turgor is not a specific or reliable sign of PCP, which is a type of pneumonia caused by a fungus that affects the lungs and respiratory system.
Correct Answer is A
Explanation
Choice A reason: Stage 4 is the remodeling stage of bone healing, which occurs from 6 to 12 weeks after the fracture. In this stage, the callus, which is a mass of fibrous tissue and cartilage that forms around the fracture site, is gradually resorbed and replaced by mature bone. The bone becomes stronger and more compact and regains its original shape and function.
Choice B reason: Stage 3 is the callus formation stage of bone healing, which occurs from 2 to 6 weeks after the fracture. In this stage, the granulation tissue, which is a soft tissue that fills the fracture gap, is replaced by a callus that bridges the fracture ends. The callus is composed of fibroblasts, chondroblasts, and osteoblasts that produce collagen, cartilage, and bone matrix. The callus stabilizes the fracture and prepares it for remodeling.
Choice C reason: Stage 5 is not a valid stage of bone healing. There are only four stages of bone healing: stage 1 is the inflammatory stage, stage 2 is the reparative stage, stage 3 is the callus formation stage, and stage 4 is the remodeling stage.
Choice D reason: Stage 1 is the inflammatory stage of bone healing, which occurs from the time of the fracture to 3 to 5 days after the fracture. In this stage, the blood vessels around the fracture site are ruptured and form a hematoma, which is a blood clot that surrounds the fracture ends. The hematoma triggers an inflammatory response that involves the release of cytokines, growth factors, and inflammatory cells that initiate the healing process. The hematoma also provides a scaffold for the granulation tissue to grow.
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