A nurse is assisting in the care of a client.
Nurses' Notes Day 1 0800:
Client is alert and oriented
Breath sounds are clear and present throughout. Denies tobacco use.
Client lives in a 20-year-old, one-story house with their partner. Client reports they just returned from an 8-hr car trip. Client eats a high fiber diet and drinks 2,000 mL of
fluid/day.
Day 1,1000:
2.5 cm x 2.5 cm (1 in x 1 in) reddened area noted on client's left calf.
Calf circumference:
Left: 40 cm (15.8 in)
Right: 38.1 cm (15 in)
Drag 1 condition and 1 client finding to fill in each blank in the following sentence. The client is at risk for developing:
lead poisoning
pneumonia
atherosclerosis
constipation
pulmonary embolism
The Correct Answer is B
The client is at risk for developing pulmonary embolism due to possible deep vein thrombosis. The rationale for this answer is based on the clinical findings noted in the nurse's notes. The presence of a reddened area on the client's calf, along with a difference in calf circumference between the left and right legs,suggests the possibility of deep vein thrombosis (DVT). DVT is a condition where a blood clot forms in a deep vein, typically in the legs. This can lead to a pulmonary embolism if a part of the clot breaks off and travels to the lungs, blocking blood flow. The client's recent long-duration car trip could have contributed to the development of DVT, as prolonged immobility is a known risk factor. The client's high fiber diet and adequate fluid intake are more likely to prevent constipation, and there is no indication of lead exposure, breath sounds issues, or atherosclerosis based on the information provided. Therefore, the most appropriate selections are 'pulmonary embolism' for the condition and 'possible deep vein thrombosis' for the client finding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Keeping the back bent while lowering the patient is not the most appropriate postion.
B. when a patient begins to fall, it is important to control the descent to minimize injury.
The nurse should widen their stance, bring the patient's body close to provide support, bend their knees, and use the strength of their thighs to lower the patient to the ground safely.
C. Keeping the knees straight while lowering the patient increases the risk of strain or injury to the nurse's back.
D. Holding the patient upright may not be feasible if the patient is already falling, and attempting to do so may result in injury to both the patient and the nurse.
Correct Answer is B
Explanation
A. Maximum assist is when the client requires total assistance from one or more persons to perform the activity. In this scenario, the client is able to rise from a seated position
independently with the assistance of a cane, so maximum assist is not appropriate.
B. Minimal assist is when the client requires some assistance or supervision to perform the activity but is able to complete most of the task independently. Since the client can rise from a seated position using a cane for support, they require minimal assistance.
C. Moderate assist is when the client requires more help than minimal assist but can still contribute to the activity. Since the client can perform the task with minimal assistance, moderate assist is not appropriate.
D. No assist is when the client is able to perform the activity without any assistance.
While the client uses a cane for support, they are still able to rise from a seated position independently, so no assist is not appropriate.
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