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.
The Correct Answer is D
Choice A rationale:
"Dull, aching calf pain.”. While dull, aching calf pain can be a symptom of deep vein thrombosis (DVT), it is not specific enough on its own to confirm the presence of a thrombus. Other conditions, such as muscle strain or injury, can also cause calf pain.
Choice B rationale:
"Positive Kernig's sign.”. Kernig's sign is typically associated with meningitis and is not relevant to the assessment of a thrombus.
Choice C rationale:
"Soft, pliable calf muscle.”. A soft and pliable calf muscle is not indicative of a thrombus. In fact, DVT is more likely to cause swelling and hardness in the affected calf due to the formation of a clot within the blood vessel.
Choice D rationale:
"Positive Homan's sign.”. A positive Homan's sign, which is elicited when dorsiflexion of the foot causes pain in the calf, can be a sign of a deep vein thrombosis (DVT). However, it is important to note that the Homan's sign is not considered a highly reliable diagnostic test for DVT, and other assessments and diagnostic tests, such as ultrasound, are typically used to confirm the presence of a thrombus.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Having the client cough and expectorate secretions is a reasonable intervention for managing respiratory distress, but it is not the top priority. The nurse should first assess the client's overall respiratory status to determine the severity of the problem.
Choice B rationale:
Instructing the client to use a pursed-lip breathing technique is a helpful strategy to improve breathing in some cases. However, it should not be the top priority when a client is experiencing difficulty breathing. Assessment should come first.
Choice C rationale:
Increasing the oxygen flow to 3 L/min without a proper assessment is not advisable. It's essential to evaluate the client's respiratory status before making any adjustments to the oxygen therapy.
Choice D rationale:
"Evaluate the client's respiratory status" is the correct response. When a client with COPD and oxygen therapy reports difficulty breathing, the nurse's priority is to assess the client's respiratory status. This assessment will help determine the cause of the breathing difficulty and guide appropriate interventions. The nurse should also check the oxygen saturation levels, respiratory rate, and auscultate lung sounds to assess the severity of the issue.
Correct Answer is D
Explanation
Choice A rationale:
Facial flushing. Facial flushing is not typically associated with atelectasis. Atelectasis is the collapse of a portion of the lung, which can lead to decreased oxygenation and respiratory distress but does not directly cause facial flushing. Flushing may be related to other factors such as fever or allergic reactions.
Choice B rationale:
Dry cough. A dry cough can be a common symptom of atelectasis. As the lung tissue collapses and airways become obstructed, it can lead to irritation and a dry, non-productive cough as the body attempts to clear the airway. So, a dry cough is an expected finding in a client with atelectasis.
Choice C rationale:
Decreasing respiratory rate. A decreasing respiratory rate is not typically associated with atelectasis. In fact, atelectasis often leads to an increased respiratory rate as the body tries to compensate for the reduced oxygen exchange. The patient may experience tachypnea (rapid breathing) as a result.
Choice D rationale:
Increasing dyspnea. Increasing dyspnea is a common and expected finding in a client with atelectasis. As lung tissue collapses and oxygen exchange is compromised, the patient will likely experience worsening shortness of breath. This is a concerning symptom and should be closely monitored, as it may indicate a need for intervention to improve lung expansion and oxygenation.
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