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 C
c. Irregular, bulging veins
Deep-vein thrombosis (DVT) is a condition characterized by the formation of a blood clot in the deep veins, commonly in the lower extremities. When assessing a client with DVT, the nurse should expect to find irregular, bulging veins in the affected extremity. This is due to the obstruction of blood flow caused by the clot, leading to distension and visible changes in the appearance of the veins.
Explanation for the other options:
a. Absent dorsal pedal pulse: Absent dorsal pedal pulse is not a characteristic finding of DVT. It may be associated with peripheral arterial disease, which is a different condition involving impaired blood flow in the arteries.
b. Shiny, hairless skin: Shiny, hairless skin is not a typical finding in the affected extremity with DVT. In fact,
the skin in the area of the clot may appear red, warm to touch, and swollen.
d. Dull, aching pain: Dull, aching pain may be present in the affected extremity with DVT. However, it is important to note that some individuals with DVT may not experience any pain or may have minimal discomfort. Therefore, the absence of pain does not rule out the possibility of DVT.
In summary, irregular, bulging veins are an expected finding in the affected extremity of a client with deep- vein thrombosis (DVT). It is important for the nurse to recognize and report these signs promptly to facilitate appropriate management and prevention of complications associated with DVT.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
b. "You feel upset by the responses of others."
The appropriate response by the nurse is to acknowledge and validate the client's feelings. Option b, "You feel upset by the responses of others," demonstrates empathy and reflects back the client's feelings, indicating that the nurse understands and acknowledges the client's distress.
Explanation for the other options:
a. "I think you should just ignore the others." This response dismisses the client's concerns and does not address the underlying issue of the client feeling hurt by the interactions with others. It is important for the nurse to address the client's feelings and provide support.
c. "Let's keep the focus of our discussion on your needs." While it is important to address the client's needs, it is also necessary to address the client's concerns and feelings related to the interactions with other clients. Ignoring or dismissing the client's concerns can further isolate the client and hinder their progress in the therapeutic environment.
d. "Everything will get beter once you get to know everyone." This response minimizes the client's feelings and does not provide immediate support or address the client's concerns. It is essential for the nurse to validate the client's emotions and explore strategies to address the issue of others making fun of the client.
In summary, the nurse should choose a response that acknowledges the client's feelings and demonstrates empathy. Validating the client's experience can help establish trust and provide a foundation for further therapeutic interventions.
Correct Answer is B
Explanation
The correct answer is b. "I will apply petroleum jelly to the penis with each diaper change."
Choice A rationale:
- It is incorrect to focus on removing all yellow exudate.A small amount of yellow exudate is normal during the healing process after circumcision.Attempting to aggressively clean it off can irritate the delicate healing tissues and cause discomfort for the baby.
- Instead,parents should gently cleanse the area with warm water during diaper changes,allowing any mild exudate to naturally drain.
Choice B rationale:
- Applying petroleum jelly with each diaper change is an essential step in promoting healing and preventing discomfort after circumcision.Here's why:
- Protects against moisture:Petroleum jelly forms a barrier that protects the delicate healing tissues from moisture from urine and feces.This helps to prevent irritation and keeps the area clean.
- Reduces friction:The lubricating properties of petroleum jelly reduce friction between the penis and the diaper,which can minimize discomfort and pain for the baby.
- Promotes healing:Petroleum jelly creates a moist environment that promotes healing and reduces scab formation.This helps the circumcision site to heal faster and more comfortably.
Choice C rationale:
- While ensuring a proper diaper fit is important for overall hygiene,it's not the most crucial aspect of post-circumcision care.A snug diaper can put unnecessary pressure on the healing penis,potentially causing irritation and discomfort.It's generally recommended to choose a diaper that fits comfortably without being too tight.
Choice D rationale:
- Using soap to wash the penis is not recommended during the healing process.Soap can be harsh and drying to the delicate tissues,potentially causing irritation and delaying healing.
- Warm water is sufficient for cleansing the area during diaper changes.
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