A nurse is planning care for a client who has deep vein thrombosis of the lower leg. Which of the following interventions should the nurse include in the plan of care?
Apply ice packs to affected leg.
Keep the client's affected leg elevated while in bed.
Have the client ambulate prior to applying antiembolic stockings.
Massage the client's affected leg twice a day.
The Correct Answer is B
A. Apply ice packs to affected leg: While ice can help reduce swelling and pain in some conditions, it is not typically recommended for deep vein thrombosis (DVT) because it could increase the risk of clot dislodgement.
B. Keep the client's affected leg elevated while in bed: Elevating the leg helps reduce swelling and promotes venous return, which is important in managing DVT.
C. Have the client ambulate prior to applying antiembolic stockings: Ambulation is usually avoided initially in the presence of DVT until anticoagulation therapy is started to reduce the risk of clot dislodgement. Antiembolic stockings should be applied after anticoagulation therapy is initiated.
D. Massage the client's affected leg twice a day: Massaging the affected leg is contraindicated in DVT as it can increase the risk of dislodging the clot, leading to complications such as pulmonary embolism.
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Related Questions
Correct Answer is ["A","C","D"]
Explanation
A. Enlarged distal extremities, such as enlarged hands and feet, are a classic sign of acromegaly. This occurs due to excess growth hormone, leading to the growth of bones and soft tissues.
B. Loss of color discrimination is not typically associated with acromegaly. This symptom is more commonly linked to other conditions, such as optic nerve disorders or macular degeneration.
C. Hepatomegaly, or an enlarged liver, is a common manifestation of acromegaly. The excess growth hormone can affect various organs, including the liver, causing them to enlarge.
D. Coarse facial features are another hallmark sign of acromegaly. The excess growth hormone causes the bones of the face, such as the jaw, nose, and brow, to enlarge, resulting in a more pronounced and coarse appearance.
E. Moon face is a characteristic of Cushing's syndrome, not acromegaly. It refers to a round, puffy face caused by excess cortisol, not growth hormone.
Correct Answer is A
Explanation
A. An S3 heart sound is known as a ventricular gallop and occurs during the rapid filling phase of the ventricle in early diastole. It is commonly heard in conditions like heart failure, where the ventricles are overfilled, or in younger individuals with healthy hearts.
B. The closure of the pulmonic valve occurs at the end of systole and is associated with the second heart sound (S2), not S3.
C. An atrial gallop is represented by an S4 sound, which occurs just before S1 when the atria contract to fill the ventricles.
D. The closure of the mitral valve occurs during S1, not S3, and marks the beginning of systole.
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