A nurse is caring for a client who is postoperative following vascular surgery.
Which of the following manifestations should indicate to the nurse that the client has developed a thrombus?
Dull, aching calf pain.
Positive Kernig's sign.
Soft, pliable calf muscle.
Positive Homan's sign.
None
None
The Correct Answer is A
The correct answer is Choice A: Dull, aching calf pain.
Choice A rationale:
Dull, aching calf pain is a common symptom of deep vein thrombosis (DVT), which can occur postoperatively, especially after vascular surgery. This pain is often due to a blood clot forming in the deep veins of the leg.
Choice B rationale:
Positive Kernig's sign is associated with meningitis and not typically related to thrombus formation.
Choice C rationale:
Soft, pliable calf muscle is not indicative of a thrombus. A thrombus would more likely cause tenderness and swelling.
Choice D rationale:
Positive Homan's sign (pain in the calf upon dorsiflexion of the foot) can be an indicator of DVT, but it is less reliable than dull, aching calf pain.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is A. Captopril.
Choice A: Captopril Captopril is an angiotensin-converting enzyme (ACE) inhibitor used to treat conditions like high blood pressure and heart failure. One of the common side effects of ACE inhibitors is a persistent, non-productive cough. This cough occurs due to the accumulation of bradykinin, a potent peptide that can induce coughing.
Choice B: Metoprolol Metoprolol is a beta-blocker used to treat high blood pressure and heart failure. Common side effects include dizziness, slow or irregular heartbeat, and unusual tiredness or weakness. However, it is not typically associated with a non-productive cough.
Choice C: Furosemide Furosemide is a loop diuretic used to treat fluid retention (edema) in people with congestive heart failure, liver disease, or a kidney disorder. While it can cause side effects like diarrhea, constipation, and loss of appetite, a non-productive cough is not a typical side effect of Furosemide.
Choice D: Digoxin Digoxin is used to treat heart failure and irregular heartbeat. Common side effects include dizziness, slow or irregular heartbeat, and unusual tiredness or weakness. However, a non-productive cough is not a typical side effect of Digoxin.
Correct Answer is D
Explanation
The correct answer is Choice D: Headache.
Rationale for Choice D (Headache): Hyponatremia, defined as a serum sodium level below 135 mEq/L, can lead to various neurological symptoms due to the altered osmotic pressure in the brain cells. When the sodium level drops below normal, water moves into the cells, causing them to swell, which can lead to increased intracranial pressure and subsequent headaches. Therefore, a client with a sodium level of 128 mEq/L is likely to experience headaches as a manifestation of hyponatremia.
Rationale for other choices:
Choice A: Hyporeflexia Hyporeflexia refers to diminished or absent reflexes. While hyponatremia can affect neurological function, hyporeflexia is not a typical manifestation. Instead, hyperreflexia may occur in severe cases due to cerebral edema and increased intracranial pressure.
Choice B: Constipation Constipation is not a common manifestation of hyponatremia. Gastrointestinal symptoms such as nausea, vomiting, and abdominal cramping may occur, but constipation is not typically associated with sodium imbalances.
Choice C: Increased appetite Hyponatremia does not typically cause increased appetite. Instead, gastrointestinal symptoms such as nausea and anorexia are more commonly observed. Increased appetite is not directly related to sodium levels but may be seen in conditions such as hyperthyroidism or certain medications.
Therefore, based on the provided data and typical manifestations of hyponatremia, the correct answer is Choice D: Headache. This is because headaches are a common neurological symptom associated with low sodium levels and increased intracranial pressure.
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