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The nurse has reviewed the Provider Prescriptions at 1355, Laboratory Results at 1450, and Diagnostic Results at 1525.

Exhibits

Complete the following sentence by using the lists of options.

The client is most likely experiencing

as evidenced by  and .
Answer and Explanation

The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A","dropdown-group-3":"A"}

Rationale for correct choices

• deep vein thrombosis (DVT): The client displays classic findings of DVT, including unilateral leg swelling, warmth, inflammation, and increased calf circumference. These findings, paired with a sedentary lifestyle and recent trauma to the leg, strongly indicate development of a thrombus in the affected extremity.

• Unequal leg circumference: The right calf measures 45.72 cm while the left measures 40.64 cm, showing significant unilateral swelling. A difference greater than 3 cm is strongly associated with DVT due to venous obstruction and impaired return, causing fluid accumulation and increased limb girth.

• Ultrasound results: The duplex ultrasound shows loss of venous compressibility and a thrombus in the right leg. These findings are diagnostic for DVT, confirming venous obstruction and establishing the cause of the client’s symptoms and leg swelling.

Rationale for incorrect choices

• undiagnosed fracture: A fracture would typically produce severe pain, deformity, or inability to bear weight, none of which are strongly present. The ultrasound confirms thrombosis, and the symptoms align more with venous obstruction than bone injury.

• cellulitis of a leg bone: Cellulitis usually presents with diffuse skin redness, warmth, and often fever. Although the leg is warm and inflamed, the presence of a venous thrombus on ultrasound and significant calf size difference more accurately support DVT rather than an infectious process.

• Difficulty walking: Difficulty walking can occur from many causes, such as arthritis or recent injury, and is not specific enough to confirm DVT. Objective findings like limb circumference and ultrasound imaging better demonstrate the underlying condition.


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Related Questions

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A,B,C"},"C":{"answers":"A,B,C"},"D":{"answers":"A,B"}}

Explanation

Rationale:

  • Sensation: Tingling indicates possible nerve irritation or mild neurovascular compromise. This is often seen in fractures when swelling or bone displacement compresses nerves near the injury site, especially in long bones like the radius.
  • Edema: Swelling is a nonspecific but common response to tissue injury. It occurs with ligament strain (sprain), bone disruption (fracture), and joint trauma (dislocation), all of which lead to localized inflammation and fluid accumulation.
  • Ecchymosis: Bruising results from soft tissue bleeding and is common in all three conditions due to trauma to blood vessels. Ligament tears (sprain), bone injury (fracture), and capsule damage (dislocation) can all lead to ecchymosis.
  • Pain level: Moderate pain, such as a 4/10 rating, is consistent with both sprains and fractures. Sprains stretch or tear ligaments, while fractures disrupt bone structure. Dislocations usually present with severe, sharp pain that impairs joint movement entirely.

Correct Answer is D

Explanation

Rationale:

A. Abdomen: The abdominal skin may be loose due to age-related changes, weight fluctuations, or prior pregnancies, making it less reliable for assessing dehydration in older adults. Lifting skin here may give a false impression of skin turgor.

B. Shoulder: Skin over the shoulder can be affected by aging, sun exposure, or decreased subcutaneous tissue, which can distort the assessment of hydration status. It is not the preferred site for older adults.

C. Neck: The skin of the neck is thin and may show wrinkles or sagging unrelated to hydration. Assessing turgor here is less accurate in older clients and may overestimate skin elasticity changes due to aging.

D. Sternum: The skin over the sternum is relatively less affected by age-related changes and provides a more reliable site for assessing turgor in older adults. Lifting this area allows the nurse to evaluate hydration status more accurately without interference from natural skin laxity elsewhere.

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