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 A
Explanation
Choice A rationale
A positive Brudzinski’s sign is indicative of meningitis. It involves involuntary lifting of the legs when the neck is flexed, suggesting meningeal irritation.
Choice B rationale
A positive Babinski’s sign indicates central nervous system pathology but is not specific to meningitis. It involves dorsiflexion of the big toe when the sole of the foot is stimulated.
Choice C rationale
A positive Romberg’s sign indicates issues with proprioception and balance but is not specific to meningitis. It involves swaying or falling when standing with eyes closed.
Choice D rationale
A positive Murphy’s sign indicates gallbladder inflammation (cholecystitis) and is not related to meningitis. It involves pain on palpation of the right upper quadrant during inspiration.
Correct Answer is A
Explanation
Choice A rationale
A respiratory rate of 28 breaths per minute indicates tachypnea, which is a sign of respiratory distress. Immediate intervention is needed to address the underlying cause and prevent further deterioration of the patient’s condition.
Choice B rationale
A temperature of 38°C (100.4°F) indicates a fever, which may suggest an infection. While this requires medical attention, it is not as immediately critical as respiratory distress.
Choice C rationale
A blood pressure of 140/90 mmHg is considered high, but it does not indicate an immediate need for intervention in the context of COPD. Hypertension should be managed, but it is not an acute emergency.
Choice D rationale
A heart rate of 90 beats per minute is within the normal range and does not indicate an immediate need for intervention. Monitoring the patient’s heart rate is important, but it is not an urgent concern in this scenario.
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