A nurse is assessing a client for possible deep vein thrombosis (DVT). Which clinical manifestation is most indicative of DVT?
Chest pain and shortness of breath.
Warmth and redness over the affected area.
Pedal edema and bilateral leg pain.
Weak pedal pulses and cool extremities.
The Correct Answer is B
A) This choice is incorrect because chest pain and shortness of breath are more indicative of a potential pulmonary embolism, a serious complication of DVT. While DVT can lead to a pulmonary embolism, the primary manifestation of DVT is related to the affected limb.
B) This choice is correct. Warmth and redness over the affected area, typically the calf or thigh, are common clinical manifestations of DVT. The warmth is due to the inflammatory response caused by the blood clot formation.
C) This choice is incorrect because pedal edema and bilateral leg pain are non-specific findings and can be caused by various conditions, not just DVT. They are not specific enough to diagnose DVT on their own.
D) This choice is incorrect because weak pedal pulses and cool extremities are not typically associated with DVT. These findings suggest potential arterial insufficiency rather than venous thrombosis.
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Related Questions
Correct Answer is C
Explanation
A) This choice is incorrect because swelling and redness in the affected leg are common clinical manifestations of DVT but are not specific to detecting potential complications like a pulmonary embolism. The nurse should focus on respiratory and cardiovascular assessments for this purpose.
B) This choice is incorrect because elevated body temperature and chills may indicate an infection but are not specific to detecting potential complications of DVT, such as a pulmonary embolism.
C) This choice is correct. Pleuritic chest pain (sharp chest pain worsened by deep breathing or coughing) and hemoptysis (coughing up blood) are classic clinical manifestations of a pulmonary embolism, a potentially life-threatening complication of DVT.
D) This choice is incorrect because abdominal pain and distension are not typical signs of a pulmonary embolism. Abdominal pain may be related to other causes, such as gastrointestinal issues.
Correct Answer is A
Explanation
A) This choice is correct. Encouraging active range of motion exercises helps prevent deep vein thrombosis (DVT) by promoting blood flow and reducing stasis in the veins. Moving the legs and ankles regularly helps prevent clot formation in immobilized clients.
B) This choice is incorrect because low-dose aspirin is not specifically indicated for preventing DVT. While aspirin may have some antiplatelet effects, it is not the primary preventive measure for DVT in high-risk clients.
C) This choice is incorrect because applying a heating pad to the affected leg is not a preventive measure for DVT. Heat application is not recommended for DVT prevention and could cause burns or injury.
D) This choice is incorrect because providing a soft mattress for the client's bed does not directly prevent DVT. The focus should be on encouraging movement and mobility to prevent DVT in clients at risk.
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