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) Administer another dose of the beta-blocker as prescribed by the physician: Administering another dose of the beta-blocker may not be the best course of action. If the client is experiencing fatigue and weakness, it could be a sign that the medication’s side effects are causing these symptoms. Administering an additional dose may exacerbate these side effects. Adjusting the medication regimen should be done under the direction of the healthcare provider.
(b) Offer the client a salty snack to improve blood pressure: Offering a salty snack may increase blood pressure, but it does not address the underlying issue of the medication’s side effects. Moreover, a diet high in salt can lead to other health problems, such as heart disease and stroke.
(c) Document the client’s symptoms and notify the healthcare provider: Documenting the client’s symptoms and notifying the healthcare provider is the most appropriate initial nursing action. The healthcare provider needs to be informed so that appropriate changes to the medication regimen can be made.
(d) Encourage the client to participate in physical therapy exercises: While physical therapy exercises can be beneficial for overall health, they do not address the immediate concern of the medication’s side effects. The client’s symptoms are indicative of medication side effects rather than a lack of physical activity. While physical therapy is important, it is not the most immediate priority in addressing the client’s current symptoms.
Correct Answer is B
Explanation
A) Describe the surgery and what the client will experience postoperatively:
While it is essential to provide information about the surgery and the postoperative experience, the primary focus of preoperative teaching is to ensure that the client understands the information provided. This option does not specifically address the client's level of understanding, which is crucial for effective teaching.
B) Reinforce information at the client's level of understanding:
This is the correct choice. When contributing to the preoperative teaching plan, the nurse should ensure that information is provided in a way that the client can comprehend. Reinforcing information at the client's level of understanding enhances communication and ensures that the client is well-informed about the procedure and what to expect.
C) Reassure the client that the surgery rarely has any negative outcomes:
While it is important to provide reassurance and support to the client, it is not appropriate to make promises or provide guarantees about the outcome of the surgery. Surgery, by its nature, carries risks, and it is essential to provide the client with accurate information while maintaining a supportive and empathetic approach.
D) Notify the client's family of the plan of care:
While it is important to involve the client's family in the plan of care, the primary focus of preoperative teaching is on the client. Involving the family in the plan of care is important, but it is not the most immediate action in the context of preoperative teaching.
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