A nurse is caring for a client.
Click to highlight the findings that require follow-up. To deselect a finding, click on the finding again.
|
Body system |
Findings |
|
Neurologic |
Client is awake, alert, oriented x3 |
|
Cardiovascular |
Client reports no palpitations, heart rhythm regular. Right lower extremity +2 edema from ankle to below the knee joint. Skin warm and inflamed: +2 pedal pulses present in bilateral extremities |
|
Musculoskeletal |
Client reports no groin pain, has slight limp with weight bearing on the right extremity |
Client is awake, alert, oriented x3
Client reports no palpitations, heart rhythm regular.
Right lower extremity +2 edema from ankle to below the knee joint.
Skin warm and inflamed
has slight limp with weight bearing on the right extremity
The Correct Answer is ["C","D","E"]
Rationale for correct choices
• Right lower extremity +2 edema from ankle to below knee: This level of edema in one limb suggests impaired venous return and is a key indicator of possible deep vein thrombosis. Unilateral swelling that develops with reduced mobility places the client at higher risk and warrants immediate assessment. Early detection is important to prevent progression to pulmonary embolism.
• Skin warm and inflamed on right lower extremity: Localized warmth and inflammation are hallmark findings of venous thrombosis or inflammatory processes in the limb. The client’s sedentary pattern and unilateral symptoms strengthen the suspicion of a vascular complication. Prompt evaluation helps guide diagnostic testing such as Doppler ultrasound.
• Slight limp with weight bearing on right extremity: A new limp combined with swelling and inflammation suggests evolving pain or functional impairment. This may indicate deep venous obstruction, localized inflammation, or injury exacerbated by reduced mobility.
Rationale for incorrect choices
• Client is awake, alert, oriented x3: This indicates intact neurological status and does not require follow-up at this time. The client shows no evidence of cognitive changes, syncope, or neurological compromise.
• Client reports no palpitations, heart rhythm regular: A regular heart rhythm without palpitations suggests stable cardiovascular status. There are no immediate arrhythmia-related concerns requiring follow-up.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
Rationale:
A. Reinforce orientation to time, place, and person: Regularly providing cues about the current time, location, and people helps reduce confusion and anxiety in clients with dementia. Orientation reinforcement supports cognitive functioning and promotes a sense of safety.
B. Refute the client’s delusions using logic: Arguing or attempting to correct delusions can increase agitation and distress. Therapeutic communication focuses on validation and redirection rather than confrontation, making this approach inappropriate for dementia care.
C. Establish eye contact when communicating with the client: Maintaining eye contact helps ensure the client’s attention and conveys engagement and respect. It enhances understanding and supports effective communication, especially when verbal comprehension may be impaired.
D. Give the client one simple direction at a time: Breaking tasks into single, clear instructions reduces cognitive overload and frustration. This approach increases the likelihood that the client can follow directions and participate successfully in activities of daily living.
E. Allow the client to choose among a variety of activities each day: While offering choices promotes autonomy, offering a large variety can be overwhelming for a client with dementia, leading to confusion, anxiety, and decision paralysis. The nurse should offer limited choices
Correct Answer is A
Explanation
Rationale:
A. Slow down the oxytocin infusion: Contractions occurring every 50 seconds and lasting 2 minutes indicate severe uterine hyperstimulation, which reduces placental blood flow and contributes to late decelerations. Slowing or stopping the oxytocin helps decrease contraction intensity and frequency, improving fetal oxygenation.
B. Administer oxygen at 2 L/min per nasal cannula: Oxygen administration can support fetal oxygenation, but 2 L/min via nasal cannula delivers minimal benefit in an acute distress situation. Oxygen would be used as a supportive measure after correcting the cause of the late decelerations. The first action is reducing uterine activity by adjusting the oxytocin infusion.
C. Place the client in a lithotomy position for delivery: Lithotomy positioning is used during the second stage of labor but is inappropriate when the fetus shows signs of distress. It does not relieve uterine hyperstimulation or improve placental blood flow. Positioning that enhances perfusion, such as side-lying, would be more beneficial after reducing the oxytocin.
D. Increase the rate of IV fluid infusion of lactated Ringers: Increasing IV fluids may help improve maternal circulation, but it does not directly resolve contractions that are too frequent or prolonged. Fluids can be an adjunct intervention but should not occur before decreasing oxytocin in the presence of late decelerations.
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