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 B
Explanation
Rationale:
A. "What questions do you have about reading food labels?": This question assesses nutrition literacy rather than dietary acculturation. It focuses on understanding nutritional information, not cultural food practices or adaptations.
B. "Do you have special customs that you follow for meals?": This question directly addresses dietary acculturation by exploring cultural or traditional food practices and meal patterns. It helps the nurse understand how the client’s cultural background influences their diet and eating behaviors.
C. "Are there any foods that you are allergic to?": This question assesses food safety and potential allergens, not cultural or acculturation aspects of the diet.
D. "How do you feel about your current body weight?": This question addresses body image and personal perception, which may influence dietary choices but does not provide information about cultural or acculturation influences on diet.
Correct Answer is A
Explanation
Rationale:
A. A client who has a prescription for compression stockings and did not receive them: Compression stockings are used to prevent deep vein thrombosis and other complications. If the client has not received them, this is a safety concern that requires immediate nursing attention. The AP should report this so the nurse can ensure the prescription is implemented.
B. A client who consumes all the food from their meal tray: Eating the entire meal indicates adequate oral intake and nutrition. While this is positive information, it does not require immediate reporting to the nurse.
C. A client who requests to sit in the bedside chair while watching TV: This is a routine activity of daily living that the AP can assist with as appropriate. It does not indicate a change in condition or a safety concern that must be reported.
D. A client who requests assistance to use the bedside commode: The AP can safely assist with toileting and does not need to report this unless there is a change in the client’s condition or an incident occurs. This is within the scope of AP duties.
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