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 D

Explanation

A. "You will be prescribed medication that will keep you well for years to come." This response provides false reassurance. Although medications can help manage angina, it does not guarantee that the client will not experience future complications.

B. "Do you have family members who died from heart disease?" This question may not address the client's immediate emotional needs and could come off as dismissive of the client's fear.

C. "You should discuss these worries with your physician." This statement redirects the client's concerns to the physician rather than addressing the client's emotional needs and fears in the moment.

D. "Tell me more about these fears." This response is therapeutic and encourages the client to express his concerns and feelings, which is a key part of addressing fear and anxiety.

A. Keep the affected knee flexed. B. Encourage increased fluid intake. C. Massage the client's calf on the affected side. D. Promote bed rest for 5-10 days.

Correct Answer is B

Explanation

A. Keep the affected knee flexed. Flexing the knee for prolonged periods can impede venous return and increase the risk of thrombosis. The knee should be extended, not flexed.

B. Encourage increased fluid intake. Encouraging fluid intake helps to prevent dehydration, which is a risk factor for blood clot formation. Adequate hydration helps keep the blood less viscous and reduces the risk of DVT.

C. Massage the client's calf on the affected side. Massaging the calf could dislodge a clot if one is present, leading to serious complications such as a pulmonary embolism. This is contraindicated.

D. Promote bed rest for 5-10 days. Early ambulation and movement are key to preventing DVT after surgery. Prolonged bed rest increases the risk of DVT due to venous stasis.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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