A nurse is collecting data from a client who requires bed rest and has developed thrombophlebitis. Which of the following findings should the nurse expect when examining the client's leg?

Cool skin

Numbness

Edema

Pallor

Answer and Explanation

The Correct Answer is C

A. Cool skin: Cool skin is not typically associated with thrombophlebitis. It is more common with arterial issues rather than venous problems.

B. Numbness: Numbness is generally a sign of nerve involvement or arterial occlusion, not a classic finding of thrombophlebitis, which primarily affects veins.

C. Edema: Edema is a common finding with thrombophlebitis due to venous inflammation and obstruction of blood flow, which leads to fluid accumulation in the affected limb.

D. Pallor: Pallor is more commonly associated with arterial insufficiency rather than venous issues like thrombophlebitis. Thrombophlebitis often presents with redness and warmth instead of pallor.

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Correct Answer is B

Explanation

A. Limit movement of the lower extremities. Limiting movement increases the risk of venous stasis, which can lead to DVT. Regular movement and ambulation are encouraged to promote blood circulation.

B. Place sequential compression devices bilaterally. Sequential compression devices (SCDs) help promote venous return and prevent venous stasis, thereby reducing the risk of DVT.

C. Massage lower extremities daily. Massaging the legs is contraindicated in clients at risk for DVT because it can dislodge a clot and lead to pulmonary embolism.

D. Check for negative Homans' sign. The Homans' sign (pain in the calf on dorsiflexion of the foot) is not a reliable indicator of DVT and is no longer recommended as a standard assessment method.

A. "Was your son born with this cardiac defect?" B. "Has your son had a sore throat recently?" C. "Has your child had any injuries recently?" D. "Are you aware that your son will have to be in isolation?"

Correct Answer is B

Explanation

A. "Was your son born with this cardiac defect?" Rheumatic fever is an acquired condition, often following a streptococcal throat infection, not a congenital (born with) cardiac defect.

B. "Has your son had a sore throat recently?" Rheumatic fever commonly follows a streptococcal throat infection, so asking about a recent sore throat is relevant and important for diagnosis.

C. "Has your child had any injuries recently?" Recent injuries are unrelated to the development of rheumatic fever and are not a pertinent question.

D. "Are you aware that your son will have to be in isolation?" Isolation is not typically required for rheumatic fever, as it is not contagious in this stage.

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A nurse is collecting data from a client who requires bed rest and has developed thrombophlebitis. Which of the following findings should the nurse expect when examining the client's leg?

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Naxlex Comprehensive Predictor Exams

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