A nurse is assessing a client who has a peripheral IV with a continuous infusion. Which of the following findings is a manifestation of phlebitis? (Select all that apply)(Select All that Apply.)
Damp dressing
Warmth at insertion site
Streak formation
Throbbing
Erythema
Correct Answer : B,C,D,E
Answer: (B, C, D, E)
Rationale:
A) Damp dressing: A damp dressing around the IV site is typically indicative of a leaking IV or infiltration, where fluid escapes from the vein into the surrounding tissue. This finding is not directly related to phlebitis, which is inflammation of the vein.
B) Warmth at insertion site: Warmth at the insertion site is a common sign of phlebitis. The inflammation of the vein causes increased blood flow to the area, leading to localized warmth. This symptom is a key indicator that the IV site may be irritated or infected.
C) Streak formation: Streak formation, often seen as a red line running along the vein above the IV site, is a classic sign of phlebitis. It indicates inflammation and irritation spreading along the vein, which can occur due to the presence of the IV catheter.
D) Throbbing: Throbbing pain or discomfort at the IV site is another sign of phlebitis. The inflammation of the vein can cause pain that may be constant or increase with movement or palpation, indicating irritation or potential damage to the vessel.
E) Erythema: Erythema, or redness at the IV site, is a hallmark sign of phlebitis. The inflammation results in redness around the insertion area, which may spread along the vein, further indicating the presence of irritation or infection at the site.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
D. Wernicke-Korsakoff psychosis is a neurological disorder caused by thiamine (vitamin B1) deficiency, often resulting from chronic alcohol use disorder. Thiamine deficiency can lead to significant neurological impairments, including confusion, ataxia, and memory deficits characteristic of Wernicke's encephalopathy and Korsakoff's psychosis.
The primary intervention for Wernicke-Korsakoff psychosis is the administration of thiamine supplementation. Thiamine replacement therapy is essential to prevent further neurological deterioration and to potentially reverse some of the cognitive deficits associated with the disorder.
The other options are not directly related to Wernicke-Korsakoff psychosis:
A. Monitoring for the presence of esophageal varices is more relevant to complications of chronic liver disease, such as cirrhosis, commonly seen in individuals with alcohol use disorder, but not specific to Wernicke-Korsakoff psychosis.
B. Placing the client in protective isolation is not indicated for Wernicke-Korsakoff psychosis. Protective isolation is typically used for clients with compromised immune systems to reduce the risk of infection.
C. Laboratory analysis of cardiac enzymes is typically performed to assess for myocardial injury or infarction, which is not directly associated with Wernicke-Korsakoff psychosis.
Correct Answer is B
Explanation
A. Dystonia - Dystonia presents as sustained or intermittent muscle contractions causing abnormal, often repetitive, movements or postures. It is an acute extrapyramidal side effect of antipsychotic medications like chlorpromazine but typically manifests as sudden-onset muscle spasms rather than involuntary movements of the tongue and face.
B. Tardive dyskinesia - Tardive dyskinesia is a late-appearing movement disorder characterized by involuntary, repetitive movements of the face, tongue, and limbs. It is associated with long-term use of antipsychotic medications like chlorpromazine and typically develops after months to years of treatment.
C. Parkinsonism - Parkinsonism resembles Parkinson's disease and is characterized by symptoms such as tremor, rigidity, bradykinesia, and postural instability. While antipsychotic medications can cause Parkinsonism as an adverse effect, it usually presents with symptoms different from those described in the scenario.
D. Akathisia - Akathisia is characterized by an inner feeling of restlessness and the urge to move, often accompanied by pacing and inability to sit still. It is an acute extrapyramidal side effect of antipsychotic medications but does not manifest as involuntary movements of the tongue and face as described in the scenario.
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