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 ["A","B","C","F"]
Explanation
Rationale:
A. "I will avoid all alcohol while taking this medication.": Alcohol can increase the risk of bleeding while a client is on anticoagulants by affecting platelet function and liver metabolism of the drug. Avoiding alcohol reduces the likelihood of complications such as gastrointestinal bleeding or excessive bruising, making this an appropriate and effective understanding of anticoagulant safety.
B. "I will ask my provider before taking any supplements.": Many herbal supplements and over-the-counter medications can interact with anticoagulants, either increasing or decreasing their effect. Consulting the provider ensures the client avoids dangerous interactions that could lead to bleeding or clotting complications.
C. "I will call my provider if I have blood in my urine.": Hematuria may indicate significant bleeding while on anticoagulant therapy. Promptly reporting this symptom allows early intervention and prevents serious complications such as anemia or renal damage, showing that the client understands the need to monitor for adverse effects.
D. "I will plan to eat a green salad every day.": While leafy green vegetables are healthy, they are high in vitamin K, which can interfere with certain anticoagulants like warfarin. Regular high intake without provider guidance could reduce the medication’s effectiveness, so this statement reflects a misunderstanding rather than effective teaching.
E. "I will stop taking the anticoagulant if I get a nosebleed.": Stopping anticoagulants without provider instruction can increase the risk of thromboembolism. Minor bleeding like a nosebleed should be reported, not managed by abruptly discontinuing the medication, so this reflects unsafe practice.
F. "I will be careful to not cut myself.": Minimizing trauma and preventing cuts or injuries is essential while on anticoagulants because even minor injuries can lead to significant bleeding. This shows the client understands the practical precautions needed to stay safe during therapy.
Correct Answer is C
Explanation
Rationale:
A. Remind the client to eat scheduled meals daily.: As clients near the end of life, appetite naturally decreases due to metabolic changes and reduced physiologic demand. Encouraging scheduled meals can create discomfort or distress and does not improve outcomes. Supportive care focuses on comfort rather than forcing nutritional intake.
B. Place the client in a supine position.: A supine position can worsen respiratory effort, increase the sensation of breathlessness, and promote secretion pooling. Terminal clients often breathe more comfortably in semi-Fowler’s or side-lying positions, which help ease ventilation and support comfort-based care.
C. Offer the client a blanket to keep warm.: Clients at the end of life commonly experience decreased body temperature due to reduced circulation and metabolic slowing. Gently providing a blanket supports comfort without invasive measures. Maintaining warmth helps ease physical distress and aligns with palliative goals focused on dignity and relief.
D. Speak in a loud tone when addressing the client.: Hearing is often the last sense to diminish, so speaking loudly is unnecessary and may startle or distress the client. A calm, soft voice preserves a peaceful environment and promotes emotional comfort, supporting both the client and family during end-of-life care.
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