A nurse is caring for a client who has deep vein thrombosis (DVT) of their right lower leg. Which of the following manifestations should the nurse expect? (Select All that Apply.)
Warmth
Erythema
Swelling
Numbness
Bleeding
Correct Answer : A,B,C
A. Warmth: Warmth over the affected area is a typical sign of DVT. It results from localized inflammation and increased blood flow due to the clot obstructing venous return and irritating the vessel wall.
B. Erythema: Erythema, or redness, often occurs in the area where the thrombus is located. It reflects the inflammatory response triggered by the presence of the clot in the vein.
C. Swelling: Swelling in the affected limb is one of the most common signs of DVT. It results from impaired venous return and fluid buildup due to the obstruction caused by the clot.
D. Numbness: Numbness is not typically associated with DVT. While swelling can sometimes compress nearby nerves and cause discomfort, numbness is not a hallmark feature and would warrant evaluation for other potential causes.
E. Bleeding: Bleeding is not a manifestation of DVT itself. DVT involves clot formation within a vein, not bleeding. However, anticoagulant therapy used to treat DVT can increase the risk of bleeding, but that is a side effect of treatment, not a sign of the condition.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Calcium level of 10.0 mg/dL (9.0 to 10.5 mg/dL): The calcium level here is normal, and insulin therapy does not directly affect calcium levels. Therefore, this is not an adverse outcome related to insulin administration.
B. Serum sodium 138 mEq/L (136 to 145 mEq/L): The sodium level is within normal range. Insulin therapy does not typically cause major shifts in sodium, so this is not a concern.
C. Serum potassium 4.8 mEq/L (3.5 to 5.0 mEq/L): The potassium level here is also within normal range. Insulin therapy is often used to lower potassium levels, so this result does not suggest an adverse effect.
D. Serum glucose 58 mg/dL (74 to 106 mg/dL): This indicates hypoglycemia, which is a well-known adverse effect of insulin therapy. When insulin is administered, especially in the context of treating hyperkalemia, it can lower blood glucose levels to dangerously low levels, leading to hypoglycemia.
Correct Answer is B
Explanation
A. Empyema: Empyema refers to the collection of pus in the pleural space, not the involvement of the entire lobe of the lung. It typically occurs as a complication of bacterial pneumonia.
B. Lobar pneumonia: Lobar pneumonia is characterized by consolidation that involves an entire lobe of the lung. This type of pneumonia typically causes more localized symptoms and is seen on chest X-rays as a distinct area of consolidation.
C. Severe pneumonia: "Severe pneumonia" is a broad term that does not specifically refer to consolidation in the lung. It may describe the clinical severity but does not denote a particular pattern of lung involvement, such as in lobar pneumonia.
D. Bronchopneumonia: Bronchopneumonia involves patchy consolidation in multiple lobes of the lungs, rather than consolidation involving an entire lobe, which is characteristic of lobar pneumonia.
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