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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

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A rationale:

Hypertension is not typically associated with low calcium levels. Hypertension is more commonly linked to issues with blood pressure regulation and not calcium levels.

Choice B rationale:

Diaphoresis (excessive sweating) is not a direct symptom of low calcium levels. Low calcium can lead to muscle cramps and tetany, but not sweating.

Choice C rationale:

Muscle tetany is a common manifestation of low calcium levels (hypocalcemia). It results from increased neuromuscular excitability, causing muscle spasms and contractions. A calcium level of 7 mg/dL is below the normal range, and this client is at risk for muscle tetany.

Choice D rationale:

Increased thirst is not a typical symptom of low calcium levels. Symptoms of hypocalcemia are primarily related to neuromuscular and cardiovascular changes, such as muscle tetany and cardiac arrhythmias.

A. Hyporeflexia. B. Constipation. C. Increased appetite. D. Headache.

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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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?

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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?