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 A
Explanation
a. "The machine is programmed to prevent you from administering more than a safe dose."
When reinforcing teaching about epidural PCA (patient-controlled analgesia) with a client in active labor, it is important for the nurse to inform the client about the safety features of the machine. By explaining that the machine is programmed to prevent the client from administering more than a safe dose, the nurse reassures the client that they have control over their pain relief while minimizing the risk of overdose.
Option b, "During medication administration, you will not be able to move your legs freely," is not an accurate statement regarding epidural PCA. While epidural analgesia may cause temporary weakness or loss of sensation in the lower body, the ability to move the legs freely is not necessarily completely impaired. The degree of mobility can vary depending on the dosage and specific characteristics of the epidural.
Option c, "This method of pain control will shorten the second stage of labor," is not a valid statement. Epidural PCA is primarily used for pain relief during labor and delivery but does not directly affect the progression or duration of the second stage of labor, which involves pushing and the delivery of the baby.
Option d, "This type of anesthesia commonly causes a postpartum headache," is also incorrect. While headaches can occur as a potential side effect of epidural anesthesia, they are not specifically associated with epidural PCA. Postpartum headaches can have various causes and are not exclusively related to the use of epidural PCA.
By emphasizing the safety features of the machine and explaining that it prevents the administration of excessive doses, the nurse ensures that the client understands the appropriate use of the epidural PCA for pain control during labor.
Correct Answer is D
Explanation
d. Increased joint stiffness due to loss of elasticity in joint cartilage.
Explanation:
The correct answer is d. Increased joint stiffness due to loss of elasticity in joint cartilage.
When teaching an older adult client about age-related changes, it is important for the nurse to provide accurate and relevant information. Joint stiffness is a commonly experienced age-related change that occurs due to the natural loss of elasticity in joint cartilage. As people age, their joints may become stiffer and less flexible, making movements and activities more challenging.
Option a is not the correct answer. Increased nail growth due to the buildup of calcium deposits is not an expected age-related change. Nail growth is primarily determined by factors such as genetics, overall health, and nutritional status, rather than calcium deposits.
Option b is not the correct answer. Increased perspiration due to overproduction by the sweat glands is not an expected age-related change. In fact, older adults may experience a decrease in the production of sweat, which can make them more susceptible to heat-related illnesses and dehydration.
Option c is not the correct answer. Increased cardiac output due to weakened heart walls is not an expected age-related change. With aging, the heart muscles may become stiffer and less efficient, leading to a decrease in cardiac output rather than an increase.
By focusing on the expected age-related change of increased joint stiffness due to loss of elasticity in joint cartilage, the nurse can provide accurate information and help the older adult client understand and manage this common aspect of the aging process.
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