The nurse is caring for the client.

Exhibits
The nurse reviews the client's history and physical and assessment findings. For each assessment finding, click to specify if the finding is consistent with a fracture or deep vein thrombosis (DVT). Each finding may support more than 1 disease process or none at all. There must be at least 1 selection in every column. There does not need to be a selection in every row.

Difficulty walking

Limb heaviness

Pain

Fever

Edema

Answer and Explanation

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.

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Correct Answer is B

Explanation

Rationale:

A. Disulfiram: Disulfiram is used to support alcohol abstinence by causing unpleasant reactions when alcohol is consumed. It does not reverse opioid overdose and is not indicated for morphine toxicity.

B. Naloxone: Naloxone is an opioid antagonist that binds to opioid receptors and rapidly reverses the effects of morphine and other opioids. It is the first-line treatment for opioid overdose, effectively restoring respiratory function and alertness.

C. Activated charcoal: Activated charcoal can adsorb certain ingested toxins in the gastrointestinal tract, but it is not effective for opioids already absorbed systemically, such as in a morphine overdose.

D. Flumaren: Flumazenil (Flumaren) is a benzodiazepine antagonist used to reverse benzodiazepine overdose, not opioid toxicity. It has no effect on morphine or other opioids.

A. A client who has a prescription for compression stockings and did not receive them. B. A client who consumes all the food from their meal tray. C. A client who requests to sit in the bedside chair while watching TV. D. A client who requests assistance to use the bedside commode.

Correct Answer is A

Explanation

Rationale:

A. A client who has a prescription for compression stockings and did not receive them: Compression stockings are used to prevent deep vein thrombosis and other complications. If the client has not received them, this is a safety concern that requires immediate nursing attention. The AP should report this so the nurse can ensure the prescription is implemented.

B. A client who consumes all the food from their meal tray: Eating the entire meal indicates adequate oral intake and nutrition. While this is positive information, it does not require immediate reporting to the nurse.

C. A client who requests to sit in the bedside chair while watching TV: This is a routine activity of daily living that the AP can assist with as appropriate. It does not indicate a change in condition or a safety concern that must be reported.

D. A client who requests assistance to use the bedside commode: The AP can safely assist with toileting and does not need to report this unless there is a change in the client’s condition or an incident occurs. This is within the scope of AP duties.

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Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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