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
Explanation
Rationale:
A. Tachycardia: Tachycardia is common in diabetic ketoacidosis (DKA) due to dehydration, electrolyte imbalances, and compensatory mechanisms for hypotension. The heart rate increases to maintain adequate perfusion in response to fluid loss and acidosis.
B. HCO3 in expected range: In DKA, bicarbonate (HCO3) levels are decreased due to metabolic acidosis. The body uses bicarbonate to buffer excess ketone acids, so HCO3 is typically below the normal range, not within expected limits.
C. Increased PaCO2: In DKA, PaCO2 is usually decreased due to Kussmaul respirations (deep, rapid breathing) as the body attempts to compensate for metabolic acidosis by blowing off CO2. Elevated PaCO2 would indicate hypoventilation, which is not characteristic of DKA.
D. Hyperreflexia: DKA does not typically cause hyperreflexia. Neurological changes, if present, are more likely to involve lethargy, confusion, or coma due to severe acidosis, dehydration, and electrolyte imbalances, rather than exaggerated reflexes.
Correct Answer is A
Explanation
Rationale:
A. "Biofeedback requires concentration to control physiological responses.": Biofeedback is a technique that helps clients gain voluntary control over involuntary bodily functions, such as muscle tension, heart rate, or skin temperature. Through focused concentration and real-time feedback from monitoring devices, clients learn to reduce stress and prevent migraine triggers.
B. “Biofeedback improves energy flow through soft tissue manipulation to increase circulation.": This description aligns more with massage or energy-based therapies, not biofeedback. Biofeedback does not involve physical manipulation of tissues but relies on monitoring and controlling physiological responses through mental focus.
C. "Biofeedback uses herbs to reduce inflammation": Herbal therapy is a complementary approach unrelated to biofeedback. Biofeedback does not incorporate herbal remedies and instead emphasizes self-regulation techniques using bio-monitoring equipment.
D. “Biofeedback stimulates certain pressure points to relax muscles": Stimulating pressure points is characteristic of acupressure or acupuncture, not biofeedback. While muscle relaxation is a goal of biofeedback, it is achieved through self-regulation and feedback, not external stimulation.
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