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A nurse is caring for a client.

Exhibits

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

 

A.

Client is awake, alert, oriented x3

B.

Client reports no palpitations, heart rhythm regular.

C.

Right lower extremity +2 edema from ankle to below the knee joint.

D.

Skin warm and inflamed

E.

has slight limp with weight bearing on the right extremity

Answer and Explanation

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.


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Related Questions

Correct Answer is B

Explanation

Rationale:

A. Report the pump has a frayed cord and proceed with the infusion: Using a pump with a frayed cord is unsafe and poses a risk of electrical shock or malfunction. The pump should not be used until it is repaired or replaced, so proceeding with the infusion is inappropriate.

B. Check the expiration date on the safety inspection sticker of the pump: Verifying that the infusion pump has a current safety inspection ensures that the device has been tested and is functioning properly. This action is essential to prevent mechanical failure and maintain patient safety during IV therapy.

C. Obtain a surge protector that can accommodate the pump and several other appliances: Infusion pumps should be plugged directly into a properly grounded outlet to ensure consistent power and prevent electrical hazards. Connecting multiple devices through a surge protector can overload the circuit and compromise pump function.

D. Verify that the extension cord for the pump is ungrounded: Using an ungrounded extension cord increases the risk of electrical shock and device malfunction. Only properly grounded outlets and cords should be used with infusion pumps to maintain safety.

Correct Answer is A

Explanation

Rationale:

A. Cheese: Aged and fermented cheeses contain high levels of tyramine, which can interact with MAOIs and cause a hypertensive crisis. Clients taking MAOIs must avoid foods rich in tyramine to prevent sudden and dangerous increases in blood pressure. This dietary restriction is a critical safety consideration when prescribing these medications.

B. Eggs: Eggs are low in tyramine and do not interact with MAOIs. They are safe to consume and provide a good source of protein for clients on this medication. No dietary restrictions are required regarding eggs.

C. Potatoes: Potatoes are low in tyramine and do not pose a risk for hypertensive crisis when taken with MAOIs. They can be included safely in the diet of clients receiving this medication.

D. Grapefruit: Grapefruit interacts with certain medications by affecting CYP450 metabolism, but it does not contain significant tyramine and is not contraindicated with MAOIs. While clients may need to avoid grapefruit with other drugs, it is not a concern specifically for MAOI therapy.

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