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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Measure the client's ankle circumference. This is a correct action, as the ankle circumference is necessary to ensure that the stockings fit snugly and provide the proper amount of compression to prevent venous stasis.
B. Measure from the client's heel to the gluteal fold. This measurement would be appropriate for thigh-high stockings, not knee-high stockings.
C. Measure from the client's heel to the popliteal space. For knee-high stockings, measuring from the heel to the popliteal space (behind the knee) ensures the stockings fit properly without cutting off circulation or causing discomfort.
D. Measure the length of the client's feet. Foot length is not necessary for knee-high stockings, as their primary function is to apply compression from the ankle to the knee.
Correct Answer is C
Explanation
A. The QT interval is equal to the R to R interval. This is not a finding associated with myocardial infarction. QT interval changes are more related to electrolyte imbalances or medication effects.
B. The QRS intervals are 0.08 second. A QRS duration of 0.08 seconds is normal and does not indicate myocardial infarction. Prolongation of the QRS complex might suggest a bundle branch block or other conduction issues.
C. The ST segment is above the isoelectric line. ST-segment elevation is a hallmark sign of an acute myocardial infarction (STEMI). It reflects injury to the heart muscle.
D. The PR intervals are 0.15 second. A PR interval of 0.15 seconds is within the normal range (0.12–0.20 seconds) and does not indicate myocardial infarction.
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