A nurse is caring for a client who is postoperative following cardiac surgery. Which of the following manifestations should indicate to the nurse that the client has developed a thrombus?
Positive Kernig's sign
Dull, aching calf pain
Soft, pliable calf muscle
Positive Homan's sign
Correct Answer : B,D
A. Positive Kernig's sign:
Positive Kernig's sign is associated with meningitis, not thrombosis. It is a clinical sign where pain is elicited when the hip is flexed at a 90-degree angle and then the knee is extended. This sign is not relevant for identifying a thrombus.
B. Dull, aching calf pain:
Dull, aching calf pain is a common symptom of deep vein thrombosis (DVT). Pain, swelling, and tenderness in the calf are typical manifestations of a thrombus in the leg veins. This symptom should alert the nurse to the possibility of a thrombus.
C. Soft, pliable calf muscle:
A soft, pliable calf muscle is not indicative of a thrombus. In the case of DVT, the affected leg is usually swollen, firm, and tender. Thus, this manifestation does not suggest the presence of a thrombus.
D. Positive Homan's sign:
Positive Homan's sign is identified when there is pain in the calf upon dorsiflexion of the foot. This sign can be indicative of DVT. Although not highly specific or sensitive, it is one of the traditional signs used to assess for the presence of a thrombus in the leg.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Eggs: While eggs are a good source of protein and other nutrients, they are also high in cholesterol. Therefore, they should be consumed in moderation on a low-cholesterol diet.
B. Liver: Liver is high in cholesterol and should be limited on a low-cholesterol diet. While it is rich in iron and other nutrients, there are other sources of these nutrients that are lower in cholesterol.
C. Beans: This is correct. Beans are a great choice for a low-cholesterol diet. They are high in soluble fiber, which can help lower cholesterol levels. They are also a good source of protein and are low in fat.
D. Milk: While milk is a good source of calcium and other nutrients, it can also be high in cholesterol, especially if it’s whole or 2% milk. On a low-cholesterol diet, it’s better to choose low-fat or non-fat dairy products
Correct Answer is D
Explanation
A. Open access peer-reviewed articles must be purchased by the user: This is not accurate. Open access articles are freely available to the public and do not require purchase.
B. Editorial opinion articles by journalists can be as relevant as peer-reviewed articles: While editorial opinion articles can provide valuable insights, they are not subjected to the same rigorous review process as peer-reviewed articles. Therefore, they are not considered as reliable or authoritative as peer-reviewed articles.
C. Peer-reviewed articles are not considered scholarly sources of evidence: This is incorrect. Peer-reviewed articles are considered one of the highest levels of scholarly sources of evidence. They have been reviewed and approved by experts in the field before publication.
D. Peer-reviewed articles have been through laborious review by other professionals: This is correct. Peer-reviewed articles undergo a rigorous review process by experts in the field, ensuring the research is of high quality and the findings are valid.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.