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

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Restlessness:

Restlessness is not typically associated with hypokalemia. Instead, it may indicate anxiety, discomfort, or other factors unrelated to electrolyte imbalances.

B. Hyperactive bowel sounds:

Hyperactive bowel sounds are often associated with increased gastrointestinal motility, which may occur in conditions such as diarrhea or gastroenteritis. While electrolyte imbalances can contribute to gastrointestinal symptoms, hyperactive bowel sounds are not specific to hypokalemia.

C. Decreased deep-tendon reflexes:

Hypokalemia can lead to decreased deep-tendon reflexes due to its effects on nerve conduction. Potassium is essential for proper nerve and muscle function, and low levels can impair reflexes.

D. Bounding peripheral pulses:

Bounding peripheral pulses are not typically associated with hypokalemia. Instead, they may indicate increased cardiac output or volume overload, which can occur in conditions such as heart failure.

A. Have the client place their head between their knees B. Plan to administer sodium bicarbonate to the client. C. Plan to administer insulin to the client D. Have the client breath into a paper bag

Correct Answer is D

Explanation

A. Have the client place their head between their knees:

Placing the head between the knees may help alleviate symptoms of hyperventilation by promoting relaxation and reducing dizziness. This position can help increase venous return to the heart and improve cerebral blood flow, which may reduce symptoms associated with hyperventilation.

B. Plan to administer sodium bicarbonate to the client:

Sodium bicarbonate is not indicated for respiratory alkalosis. It is used to treat metabolic acidosis by increasing plasma bicarbonate levels. Administering sodium bicarbonate to a client with respiratory alkalosis may exacerbate the alkalosis by further increasing the pH of the blood.

C. Plan to administer insulin to the client:

Insulin administration is not indicated for respiratory alkalosis. Insulin is used to manage hyperglycemia in diabetes mellitus and does not address the underlying respiratory condition causing alkalosis.

D. Have the client breathe into a paper bag:

Breathing into a paper bag is a common intervention for managing hyperventilation associated with respiratory alkalosis. Rebreathing exhaled carbon dioxide helps increase carbon dioxide levels in the blood, which can reverse the alkalosis and alleviate symptoms of hyperventilation.

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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?

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Naxlex Comprehensive Predictor Exams

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Explanation

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