The nurse has reviewed the Provider Prescriptions at 1355, Laboratory Results at 1450, and Diagnostic Results at 1525.
Complete the following sentence by using the lists of options.
The client is most likely experiencing
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. "Why did this happen to me?": This statement reflects the anger stage of grief, where the client questions fairness and expresses frustration about their situation. It does not involve negotiating or making promises in exchange for a desired outcome.
B. "I never did anything bad to hurt anyone": This reflects the guilt or depression stage, as the client may be feeling remorse or self-blame related to their illness. It is an emotional expression rather than an attempt to bargain.
C. "I hope my family can accept what's happening": This reflects the acceptance stage, where the client begins to come to terms with their prognosis and focuses on reconciliation or emotional resolution.
D. "If I get better I will study to become a priest.": This is an example of the bargaining stage, where the client attempts to negotiate or make promises in exchange for a desired outcome, such as improved health or extended life. It demonstrates the “what if” reasoning characteristic of this stage of grief.
Correct Answer is D
Explanation
Rationale:
A. Arrange for a meeting with the child's guardians tomorrow: Meeting with the guardians may be appropriate later, but initially, the nurse must follow mandatory reporting laws. Waiting to meet could delay protection for the child and place them at further risk.
B. Notify the president of the school board: Reporting to school administration does not replace legal obligations to report suspected child abuse. The school board president is not the appropriate authority for immediate child protection.
C. Ask the child's peers about the bruises: Questioning peers is inappropriate and could violate privacy or compromise the investigation. The nurse should not attempt to investigate the situation personally.
D. Report the findings to child protective services: As a mandated reporter, the nurse is legally required to report any suspected child abuse immediately to child protective services. This action ensures the child’s safety and initiates an official investigation.
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