A nurse is assessing a client with a temperature of 38°C (100.4°F) and notes a red, swollen area on the client’s leg. Which condition is the client most likely experiencing?
Cellulitis.
Deep vein thrombosis.
Osteomyelitis.
Gout.
The Correct Answer is A
Choice A rationale
Cellulitis is characterized by a red, swollen, and warm area on the skin, often accompanied by fever. It is a bacterial infection of the skin and underlying tissues.
Choice B rationale
Deep vein thrombosis (DVT) typically presents with swelling, pain, and warmth in the affected leg but not redness and fever as primary symptoms.
Choice C rationale
Osteomyelitis involves infection of the bone, presenting with localized pain, swelling, and fever, but not typically a red, swollen area on the skin.
Choice D rationale
Gout causes joint pain, swelling, and redness, usually in the big toe, but not a red, swollen area on the leg.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Increased thirst is a symptom of hyperglycemia, not hypoglycemia. It occurs when high blood sugar levels cause dehydration.
Choice B rationale
Increased appetite can occur in hypoglycemia but is not as specific as other symptoms like slurred speech.
Choice C rationale
Slurred speech is a common symptom of hypoglycemia, indicating that the brain is not receiving enough glucose to function properly.
Choice D rationale
Polyuria is a symptom of hyperglycemia, where excess glucose in the blood leads to increased urine production.
Correct Answer is B
Explanation
Choice A rationale
Administering sodium polystyrene sulfonate helps to lower potassium levels by exchanging sodium ions for potassium ions in the intestines. However, it is not the first intervention because it takes time to work and does not address the immediate risk of cardiac arrhythmias caused by hyperkalemia.
Choice B rationale
Monitoring the client’s cardiac rhythm is the first intervention because hyperkalemia can cause life-threatening cardiac arrhythmias. Continuous cardiac monitoring allows for the early detection and treatment of these arrhythmias, which is crucial for the client’s safety.
Choice C rationale
Restricting dietary potassium intake is an important long-term management strategy for hyperkalemia, especially in clients with chronic kidney disease. However, it does not address the immediate risk of cardiac arrhythmias and is not the first intervention.
Choice D rationale
Preparing the client for hemodialysis is a definitive treatment for hyperkalemia, especially in clients with chronic kidney disease. However, it is not the first intervention because it takes time to arrange and initiate dialysis. Immediate cardiac monitoring is necessary to manage the acute risk of arrhythmias.
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