The nurse is caring for the client.
Difficulty walking
Limb heaviness
Pain
Fever
Edema
The Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"B"},"C":{"answers":"A,B"},"D":{"answers":"B"},"E":{"answers":"B"}}
Rationale:
• Difficulty walking: Bone injury limits weight-bearing ability and causes alterations in gait. Localized pain and instability can make ambulation difficult. Clients often compensate with limping to avoid pressure on the injured limb. In DVT, A clot in the deep veins causes swelling and discomfort, making ambulation painful. The heaviness and fullness in the limb interfere with normal gait. Clients may develop a limp due to localized tenderness.
• Pain: A fracture typically produces sharp, localized pain that worsens with movement. Tissue disruption and swelling contribute to discomfort. The pain limits limb use and is often immediate after injury. DVT often causes aching or cramping pain in the affected limb, especially with walking. Venous congestion and inflammation contribute to tenderness. Pain increases when the calf is compressed or when standing.
• Limb heaviness: Venous obstruction causes blood pooling, producing a heavy and tight sensation. This finding reflects impaired venous return, especially when swelling is also present. It is common in unilateral DVT. A fracture typically causes sharp, localized pain rather than diffuse heaviness. Heaviness is more strongly associated with venous congestion.
• Fever: Low-grade fever may occur due to inflammatory response around the thrombus. Cytokine release produces systemic symptoms during clot formation. It can accompany swelling, warmth, and redness. A simple fracture does not generally cause systemic fever unless infection develops. Fever is more indicative of inflammatory or infectious conditions.
• Edema: Venous blockage leads to unilateral swelling due to trapped fluid and elevated venous pressure. The affected limb becomes warm, enlarged, and firm. This is a hallmark finding in deep vein thrombosis. While swelling may occur after a fracture, the client’s presentation shows significant unilateral edema matching venous obstruction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D","E","G"]
Explanation
Rationale for correct choices
• The statement "Why don't you just leave me? I am of no use" reflects hopelessness, a high‑risk indicator for self‑harm in older adults. Expressions of worthlessness or being a burden require immediate follow‑up because they signal severe depression or suicidal ideation. The priority is ensuring safety and initiating urgent mental health evaluation.
• The report of cognitive decline accompanied by worsening memory, disordered thought process, and impaired self‑care indicates a significant functional deterioration. These symptoms can reflect rapidly progressing depression, delirium, or early dementia. Any acute decline in cognition or functional ability in an older adult warrants prompt assessment to identify reversible causes.
• Loss of appetite with an 8‑lb weight loss in one month suggests clinically significant unintentional weight loss. Combined with decreased interest in eating, this is a red flag for major depressive disorder, frailty progression, or underlying illness. Sudden nutritional decline increases morbidity risk and requires timely intervention.
• Poor eye contact, monotone speech, and flat facial expression are key affective indicators of depression. These signs, when combined with statements of worthlessness, suggest severe depressive symptoms that require urgent assessment and intervention to prevent further decline.
Rationale for incorrect choices
• Sleeping 7 hours per night with 1–2 awakenings to urinate can be normal for older adults. This finding does not indicate acute risk and is not a priority compared with weight loss, cognitive decline, or suicidal statements. It can be evaluated during routine assessment rather than requiring urgent follow‑up.
• Heart rate 68/min is within normal limits for an older adult and does not signal instability or deterioration. It does not require immediate intervention and can be monitored routinely while priority concerns related to mood, cognition, and safety are addressed.
Correct Answer is C
Explanation
Rationale:
A. Restrict daily exercise: Clients with heart failure benefit from regular, moderate activity as tolerated to improve cardiac efficiency and prevent deconditioning. Restricting all exercise can worsen functional status and is not recommended unless specifically limited by the healthcare provider.
B. Encourage 3 large meals per day: Large meals can increase cardiac workload and exacerbate heart failure symptoms due to increased blood flow demands during digestion. Smaller, more frequent meals are preferable to reduce strain on the heart.
C. Limit dietary salt intake: Reducing sodium intake helps prevent fluid retention and edema, which can exacerbate heart failure and increase cardiac workload. Teaching clients to limit salt is a key intervention to manage decreased cardiac output and maintain stable fluid balance.
D. Obtain weight once per week: Daily weight monitoring is recommended for clients with heart failure to detect fluid retention early. Weekly weights may delay recognition of sudden fluid accumulation, increasing the risk of decompensation.
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