An obese post-surgical patient reports sudden discomfort in her leg.

Upon assessment, the nurse finds the leg to be cold and pale, with no pedal or popliteal pulse. What should the nurse suspect?

Venous thrombosis.

Paresthesia.

Vascular spasm.

Arterial occlusion.

Answer and Explanation

The Correct Answer is D

Choice A rationale
Venous thrombosis is a condition in which a blood clot forms in a vein, typically in the leg. While this condition can cause discomfort and changes in the appearance of the leg, it would not typically cause the leg to become cold and pale or result in the loss of a pulse.
Choice B rationale
Paresthesia refers to abnormal sensations in the body, such as tingling, numbness, or burning. While this condition could potentially cause discomfort, it would not typically cause the leg to become cold and pale or result in the loss of a pulse.
Choice C rationale
Vascular spasm is a sudden, brief tightening of the muscles inside the walls of a blood vessel. While this could potentially cause discomfort and changes in the appearance of the leg, it would not typically cause the leg to become cold and pale or result in the loss of a pulse.
Choice D rationale
Arterial occlusion is the correct answer. This condition involves a blockage in an artery, which can significantly reduce blood flow to the affected area. This could cause the leg to become cold and pale and result in the loss of a pulse.

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Correct Answer is B

Explanation

Choice A rationale
Cracked lips are a symptom of Kawasaki disease, but they are more commonly associated with the subacute phase of the disease, not the acute phase.
Choice B rationale
Conjunctival hyperemia, or redness of the whites of the eyes, is a common symptom in the acute phase of Kawasaki disease. It typically presents as bilateral, non-exudative conjunctival injection, primarily in the bulbar conjunctivae.
Choice C rationale
A normal appearance is not typically seen in the acute phase of Kawasaki disease, which is characterized by a high fever and at least four of the five main symptoms, including conjunctival hyperemia.
Choice D rationale
Desquamation of the skin, or peeling, is a symptom of Kawasaki disease, but it typically occurs in the subacute phase, not the acute phase.

A. Begin cardiopulmonary resuscitation (CPR). B. Cardiovert the client with a biphasic defibrillator. C. Assess airway, breathing, and circulation. D. Administer an amiodarone bolus followed by a drip.

Correct Answer is C

Explanation

Choice A rationale
Beginning cardiopulmonary resuscitation (CPR) is not the first action a nurse should take when a patient’s heart monitor shows a pattern of undulations of varying contours and amplitude with no measurable ECG pattern.
Choice B rationale
Cardioverting the client with a biphasic defibrillator is not the first action a nurse should take when a patient’s heart monitor shows a pattern of undulations of varying contours and amplitude with no measurable ECG pattern.
Choice C rationale
The first action a nurse should take when a patient’s heart monitor shows a pattern of undulations of varying contours and amplitude with no measurable ECG pattern is to assess the patient’s airway, breathing, and circulation.
Choice D rationale
Administering an amiodarone bolus followed by a drip is not the first action a nurse should take when a patient’s heart monitor shows a pattern of undulations of varying contours and amplitude with no measurable ECG pattern.

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An obese post-surgical patient reports sudden discomfort in her leg. Upon assessment, the nurse finds the leg to be cold and pale, with no pedal or popliteal pulse. What should the nurse suspect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

As a nurse preparing for the admission of a child diagnosed with acute-stage Kawasaki disease, what clinical manifestation of the acute stage of the disease should be anticipated during the assessment?

Correct Answer is B

Explanation

A nurse is caring for a client on a cardiac monitor. The patient’s heart monitor shows a pattern of undulations of varying contours and amplitude with no measurable ECG pattern. What is the first action the nurse should take?

Correct Answer is C

Explanation

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An obese post-surgical patient reports sudden discomfort in her leg.

Upon assessment, the nurse finds the leg to be cold and pale, with no pedal or popliteal pulse. What should the nurse suspect?