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 D
Explanation
Rationale:
A. Administer a continuous infusion of calcium gluconate: Calcium gluconate is not used for the management of preeclampsia or seizure prophylaxis. Magnesium sulfate is the medication of choice to prevent eclamptic seizures in clients with severe preeclampsia.
B. Place the client in the semi-Fowler's position: Semi-Fowler’s position does not optimize uteroplacental perfusion. Left lateral positioning is preferred to enhance blood flow to the uterus and improve maternal and fetal oxygenation.
C. Ensure bright lighting in the room: Bright lighting can increase stimulation and anxiety, which is not beneficial for a client at risk for seizures. A calm, low-stimulation environment is preferable to minimize seizure triggers.
D. Initiate seizure precautions: Clients with preeclampsia with severe features are at high risk for eclampsia, making seizure precautions essential. These include placing the bed in a low position, padding side rails, having oxygen and suction available, and monitoring closely for neurologic changes.
Correct Answer is A
Explanation
Rationale:
A. "You have the right to decide who receives information.": Clients have the legal and ethical right to confidentiality regarding their medical care under HIPAA and patient privacy regulations. Respecting the client’s decision about who can receive health information reinforces autonomy and ensures that the nurse supports the client’s rights in healthcare decision-making.
B. "Your partner can be a great source of support for you at this time.": While acknowledging the potential benefits of support is empathetic, this statement does not address the client’s request for privacy. It may inadvertently pressure the client to share information, which could violate confidentiality and autonomy.
C. "Is there a reason you don't want your partner to know about your procedure?": Asking for justification may make the client feel challenged or judged. The client is not required to explain their choice, and pressing for reasons can undermine trust and respect for their privacy.
D. "The provider will be tactful when talking to your partner.": This statement assumes the provider will communicate with the partner and disregards the client’s expressed wishes. It could lead to disclosure against the client’s consent, violating confidentiality and patient rights.
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