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 A

Explanation

(A) Heart murmur: This is the most appropriate answer. Mitral valve stenosis can cause a heart murmur due to turbulent blood flow across the narrowed mitral valve. This is often heard best at the apex of the heart with the patient in the left lateral decubitus position.

(B) Clubbing of the fingers: Clubbing of the fingers is typically associated with conditions that cause chronic hypoxia, such as lung disease or congenital heart disease. It is not a common finding in mitral valve stenosis.

(C) Bradycardia: Mitral valve stenosis does not typically cause bradycardia. In fact, some patients may have a rapid heart rate (tachycardia) due to atrial fibrillation, which is a common complication of mitral valve stenosis.

(D) Barrel chest: A barrel chest is typically associated with chronic obstructive pulmonary disease (COPD) and is not a common finding in mitral valve stenosis. It refers to a rounded, bulging chest that resembles the shape of a barrel. This occurs due to overinflation of the lungs over a long period of time.

A. An adolescent who asks to stay in the hospital because he likes the room B. A toddler who has multiple bruises on the shins of both legs and his parents report that he is clumsy C. A school-age child who cries when the nurse is giving him an injection D. A preschooler who has a BMI indicating obesity

Correct Answer is A

Explanation

Answer: A. An adolescent who asks to stay in the hospital because he likes the room

Rationale:

A) An adolescent who asks to stay in the hospital because he likes the room: This finding may indicate that the adolescent is experiencing abuse or neglect at home. A desire to remain in the hospital could suggest that the child views it as a safe space compared to their home environment, warranting further assessment for possible abuse.

B) A toddler who has multiple bruises on the shins of both legs and his parents report that he is clumsy: Bruising on the shins is common in toddlers due to normal exploratory behavior and frequent falls. The parent's explanation aligns with developmental norms, making this finding less indicative of abuse.

C) A school-age child who cries when the nurse is giving him an injection: Crying during injections is a typical reaction for school-age children and does not suggest abuse. Emotional responses to medical procedures are age-appropriate and expected.

D) A preschooler who has a BMI indicating obesity: While obesity in children may raise concerns about diet and lifestyle, it is not inherently indicative of abuse. Further evaluation may be needed for nutritional and health interventions but does not typically suggest maltreatment.

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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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