A nurse is assessing a client who has intravenous therapy-related phlebitis. The nurse uses the Infusion Nurses Society's phlebitis scale to assess the severity of phlebitis and documents the client's phlebitis as grade level 1. Which of the following assessment findings correlates with a grade level of 1?

Purulent drainage at the intravenous site access site.

Redness at the intravenous access site with pain.

Red streaks on the affected extremity.

Palpable venous cord in the affected extremity.

Answer and Explanation

The Correct Answer is B

Choice A reason:
Purulent drainage at the intravenous site access site would indicate a more severe infection, possibly grade 3 or 4 on the Infusion Nurses Society's phlebitis scale. This would be associated with more advanced symptoms such as pus formation, which is not characteristic of grade 1 phlebitis.

Choice B reason:
Redness at the intravenous access site with pain is indicative of grade 1 phlebitis according to the Infusion Nurses Society's phlebitis scale. This grade is characterized by erythema and possible pain at the site of the IV insertion, without more severe symptoms such as swelling or streak formation.

Choice C reason:
Red streaks on the affected extremity suggest a progression of the inflammatory response, potentially indicating a higher grade of phlebitis, such as grade 2 or 3. This symptom suggests that the inflammation is spreading along the vein, which is more serious than grade 1 phlebitis.

Choice D reason:
A palpable venous cord in the affected extremity would also suggest a more severe form of phlebitis, likely grade 3. This occurs when a thrombus forms along with inflammation of the vein, leading to a palpable cord-like structure.

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Correct Answer is A

Explanation

Choice A reason:
Arthralgia, or joint pain, is a common symptom associated with heterotopic ossification (HO), especially when it occurs near joints. The ectopic bone formation can lead to restricted movement and pain during joint movement.

Choice B reason:
Bradycardia, or a slower than normal heart rate, is not directly associated with HO. While spinal cord injuries can affect autonomic control and potentially lead to bradycardia, it is not a symptom specifically linked to the presence of HO.

Choice C reason:
Fecal impaction may occur in patients with spinal cord injuries due to mobility issues and changes in bowel function, but it is not a direct result of HO. HO does not typically affect bowel movements unless the ossification is in a location that mechanically obstructs the bowel.

Choice D reason:
Hypertension, or high blood pressure, is not a symptom commonly associated with HO. While individuals with spinal cord injuries may experience dysregulation of blood pressure, this is not specifically related to HO.

A. Hypotension B. Poor skin turgor C. Ataxia D. Dilute urine

Correct Answer is C

Explanation

Choice A reason: Hypotension
Hypotension, or low blood pressure, can be a consequence of dehydration, which is a common complication of DI due to the excessive loss of water. However, hypotension is not a direct neurological effect of DI. It is more of a circulatory system response to the changes in fluid volume within the body.

Choice B reason: Poor skin turgor
Poor skin turgor is an indicator of dehydration, which can occur in DI due to the large volume of urine excreted. Skin turgor refers to the skin's ability to change shape and return to normal (elasticity), and it becomes less elastic when the body is dehydrated. While this is an important sign to monitor, it is not a neurological effect.

Choice C reason: Ataxia
Ataxia, which is a lack of muscle coordination affecting speech, eye movements, the ability to swallow, walking, picking up objects, and other voluntary movements, can be a neurological effect of DI if severe dehydration and electrolyte imbalance affect the brain. Symptoms such as confusion and muscle cramps can also be associated with ataxia, making it a relevant neurological effect to monitor in a client with DI.

Choice D reason: Dilute urine
Dilute urine is a primary symptom of DI, not a neurological effect. It is the result of the kidneys' inability to concentrate urine due to a deficiency in the anti-diuretic hormone (ADH) or the kidneys' response to ADH. Monitoring urine concentration is crucial in managing DI, but it does not represent a neurological effect.

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has a spinal cord injury with heterotopic ossifications. Which of the following findings should the nurse expect?

Correct Answer is A

Explanation

A nurse is providing care for an older adult client who has diabetes insipidus (DI). The nurse should monitor the client for which of the following neurological effects?

Correct Answer is C

Explanation

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