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

dropdown

due to deep vein thrombosis

 

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.

A. Deep vein thrombosis (DVT) is a condition characterized by the formation of blood clots in deep veins, commonly occurring in the lower extremities. DVT can be acquired during hospitalization due to factors such as immobility, surgery, or certain medical treatments.
B. Hypothyroidism, diabetes mellitus, and hypertension are chronic medical

conditions that may be managed or exacerbated during hospitalization but are not typically considered hospital-acquired injuries. They are often present before
hospitalization and may require ongoing management during the hospital stay.

C. Diabetes mellitus is a chronic condition characterized by elevated blood sugar levels due to either insufficient insulin production or the body's inability to use
insulin effectively. While diabetes management may be necessary during

hospitalization, it is not considered a hospital-acquired injury. Instead, it is a pre- existing condition that requires ongoing monitoring and treatment.

D. Hypertension, or high blood pressure, is a chronic condition that may require management during hospitalization but is not typically considered a hospital- acquired injury. Hypertension is often managed with medications and lifestyle modifications and may be monitored and treated during the hospital stay.