The home care nurse provided self-care instructions for a client with chronic venous insufficiency caused by deep vein thrombosis. Which instruction(s) should the nurse include in the client's discharge teaching plan? (Select all that apply.)
Avoid prolonged standing or sitting.
Continue wearing compression stockings.
Cross legs at knee but not at ankle.
Use recliner for long periods of sitting.
Maintain the bed flat while sleeping.
Correct Answer : A,B,D
A. Prolonged standing or sitting can worsen venous insufficiency and increase the risk of blood pooling in the legs. Encouraging the client to move around and avoid prolonged periods of immobility can help improve circulation.
B. Compression stockings help improve blood flow by applying pressure to the legs, reducing swelling and preventing blood from pooling. The client should be instructed to continue wearing them as prescribed by their healthcare provider.
C.Crossing the legs can impede blood flow and should be avoided altogether.
D. Sitting for extended periods can also contribute to blood pooling. Using a recliner allows the client to elevate their legs, promoting better circulation and reducing the risk of complications. The nurse should recommend using a recliner when sitting for long periods of time.
E. Elevating legs during sleep is generally advised to reduce venous pressure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale: White blood cell count monitors for infection or inflammation. While important for general health, it does not address the massive fluid loss and electrolyte imbalances specifically caused by diabetes insipidus.
Choice B rationale: Capillary glucose monitors for diabetes mellitus. Diabetes insipidus involves antidiuretic hormone deficiency, not insulin issues; therefore, glucose levels are not the priority in managing the massive dilute polyuria seen here.
Choice C rationale: Urine specific gravity will be consistently low in diabetes insipidus. While it confirms the diagnosis of dilute urine, it is less critical than monitoring the life-threatening systemic effects of dehydration.
Choice D rationale: Serum sodium is the most important lab to monitor. Massive loss of dilute urine leads to severe hemoconcentration and hypernatremia, which can cause cerebral edema, seizures, and permanent neurological damage.
Correct Answer is A
Explanation
A) Correct- With a significantly low platelet count, the risk of bleeding is elevated. Assessing urine and stool for occult (hidden) blood is important to detect any signs of internal bleeding that may not be immediately apparent. A low platelet count increases the risk of spontaneous bleeding, which can be life-threatening if undetected.
B) Incorrect- This choice is related to neutropenia, not thrombocytopenia. Neutropenia, or low neutrophil count, increases the risk of infection, which is why monitoring temperature frequently is important.
C) Incorrect- Monitoring for signs of activity intolerance is not directly related to the low platelet count. The primary concern with thrombocytopenia is the risk of bleeding, not generalized activity intolerance.
D) Incorrect- Requiring visitors to wear respiratory masks is not relevant to the client's current condition of low platelet count. This action is related to infection control and protection from respiratory infections.
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