A nurse is collecting data from a client who is 1 day postoperative following a total hip arthroplasty and has
deep-vein thrombosis. Which of the following findings should the nurse expect in the affected extremity?
Absent dorsal pedal pulse
Shiny, hairless skin
Irregular, bulging veins
Dull, aching pain
The Correct Answer is D
Choice A:
An absent dorsal pedal pulse would indicate a vascular problem such as arterial occlusion, not a deep vein thrombosis (DVT). In the case of DVT, blood flow in the veins is obstructed, but the arterial pulse, which is related to arterial circulation, should remain intact unless there is a separate arterial issue. Therefore, absent pulses are not characteristic of DVT.
Choice B:
Shiny, hairless skin is a sign typically associated with chronic arterial insufficiency, not DVT. This skin change occurs when there is poor arterial blood flow, which leads to a lack of nourishment for the skin, causing it to become thin and shiny. In contrast, DVT affects the veins and does not usually cause these skin changes in the acute phase.
Choice C:
Irregular, bulging veins are indicative of varicose veins or chronic venous insufficiency, not a DVT. Varicose veins occur when the veins become swollen and twisted due to weak or damaged valves. DVT, on the other hand, involves the formation of a clot in the deep veins and does not typically cause the veins to bulge visibly, especially in the early stages.
Choice D:
Dull, aching pain is a common symptom associated with deep vein thrombosis. This pain typically occurs in the affected extremity and is often described as a constant, aching sensation. The pain can worsen with movement or standing and is due to the inflammation and obstruction caused by the blood clot in the deep veins. This is a hallmark sign of DVT, along with swelling and redness in the affected limb.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
When taking allopurinol, a medication commonly used to treat gout and prevent kidney stones, the nurse should instruct the client to monitor and report the manifestation of a skin rash with fever. Stevens-Johnson syndrome (SJS) is a severe and potentially life-threatening condition that can occur as a rare side effect of allopurinol. It is characterized by a widespread rash, often with fever, and can progress to involve the mucous membranes (e.g., mouth, eyes) and cause severe complications.
The other manifestations mentioned, such as diplopia (double vision), tinnitus with ear pain, and hyperreflexia (exaggerated reflexes), are not typically associated with Stevens-Johnson syndrome and should not be directly attributed to this condition. However, it's important for the client to report any unusual or severe symptoms to their healthcare provider for further evaluation and appropriate management.
Correct Answer is B
Explanation
b. A client who has hemiparesis and lives alone.
Explanation:
The correct answer is b. A client who has hemiparesis and lives alone.
An interdisciplinary care conference involves the collaboration of multiple healthcare professionals from different disciplines to develop a comprehensive care plan for a client. In this scenario, the client with hemiparesis who lives alone requires an interdisciplinary care conference because their condition and living situation present complex challenges.
Clients who had surgery for cataract removal and live in a rural location (option a) may require support with transportation and follow-up appointments, but it does not necessarily warrant an interdisciplinary care conference.
A client who requires assistance to pay for dressing supplies (option c) may benefit from financial counseling or resources, but it does not typically require the involvement of multiple healthcare professionals in a care conference.
A client who requires instruction regarding medication administration (option d) can typically receive education from a nurse or pharmacist without the need for an interdisciplinary care conference.
In contrast, the client with hemiparesis who lives alone may require input from various professionals such as physical therapists, occupational therapists, social workers, and home healthcare providers to address their physical limitations, safety concerns, and support needs. Therefore, an interdisciplinary care conference is necessary to develop a comprehensive discharge plan that addresses all aspects of their care and promotes their well-being in the community.
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