A nurse is assessing a client who has a left lower arm fracture. Which of the following findings indicates impaired venous return in the client’s affected arm?

Acute pain

Ecchymosis of the surrounding skin

Increasing edema

Diminishing distal pulse

Answer and Explanation

The Correct Answer is C

Choice A reason: Acute pain is expected with a fracture but does not specifically indicate impaired venous return.

Choice B reason: Ecchymosis, or bruising, can occur with a fracture due to bleeding into the tissue but is not a direct indicator of venous return issues.

Choice C reason: Increasing edema is a sign of impaired venous return as it indicates a buildup of fluid in the tissues, which can occur if the veins are not effectively returning blood to the heart.

Choice D reason: A diminishing distal pulse could indicate arterial impairment rather than venous return issues.

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Correct Answer is C

Explanation

Choice A reason: Fatigue is a common symptom of ITP but is not the primary concern for monitoring, as it does not directly indicate the severity of the condition.

Choice B reason: While monitoring for side effects of immunosuppressants is important, it is not the priority concern. The primary issue in ITP is the low platelet count, which poses a risk of bleeding.

Choice C reason: Thrombocytopenia, or low platelet count, is the hallmark of ITP and the main concern for monitoring, as it increases the risk of bleeding and bruising.

Choice D reason: Infection is a risk due to the potential use of immunosuppressants in treatment; however, the immediate concern in ITP management is the platelet count and associated bleeding risk.

A. Are you taking a multivitamin? B. Have you had a recent influenza infection? C. Have you traveled overseas recently? D. Do you have a history of chronic alcohol abuse?

Correct Answer is B

Explanation

Choice A reason: Asking about multivitamin intake is not directly relevant to GBS, as the syndrome is not known to be caused by vitamin deficiencies or related to nutritional status.

Choice B reason: A recent influenza infection is relevant because GBS is often preceded by an infection, such as a respiratory or gastrointestinal viral infection. The immune system's response to this infection may mistakenly attack peripheral nerves, leading to GBS.

Choice C reason: While travel history is important in assessing exposure to infectious diseases, it is less specific than asking about recent infections. GBS can occur after exposure to certain viruses or bacteria, which can be contracted without overseas travel.

Choice D reason: Chronic alcohol abuse is a risk factor for various neurological conditions, but it is not a typical precursor to GBS. The syndrome is more commonly associated with immune responses to infections.

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A nurse is assessing a client who has a left lower arm fracture. Which of the following findings indicates impaired venous return in the client’s affected arm?

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Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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