The nursing care plan for a client in traction includes regular assessments for venous thromboembolism. When assessing a client's lower limbs, what sign or symptom is suggestive of deep vein thrombosis (DVT)?
Increased circulation of the calf
Pale-appearing calf
Increased warmth in the calf
Loss of sensation to the calf
Swelling and tenderness of the calf
The Correct Answer is E
Choice A reason: Increased circulation of the calf is not a sign or symptom of DVT, but a normal finding of the blood flow in the leg. It can be assessed by palpating the pulses, checking the capillary refill, or observing the skin color and temperature.
Choice B reason: Pale-appearing calf is not a sign or symptom of DVT, but a sign of arterial insufficiency or ischemia. It indicates the reduced blood supply and oxygen delivery to the tissues, which can cause pain, numbness, or coldness of the leg.
Choice C reason: Increased warmth in the calf is not a specific sign or symptom of DVT, but a possible sign of inflammation or infection. It may be accompanied by redness, swelling, or fever, which can indicate a local or systemic inflammatory response.
Choice D reason: Loss of sensation to the calf is not a sign or symptom of DVT, but a sign of nerve damage or compression. It may be caused by trauma, injury, diabetes, or other conditions that affect the peripheral nervous system.
Choice E reason: Swelling and tenderness of the calf is a common sign or symptom of DVT, as it indicates the presence of a blood clot in the deep veins of the leg. It may also cause pain, cramping, or heaviness of the leg, which can worsen with movement or standing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is E
Explanation
Choice A reason: Use of sequential compression devices (SCDs) during times of rest is a helpful intervention to prevent DVT, as it improves the venous return and reduces the stasis of blood in the lower extremities. However, it is not the only or the most effective intervention, as it does not promote the active contraction of the leg muscles.
Choice B reason: Use of abductor pillow while in bed is a necessary intervention to prevent hip dislocation after total hip replacement, as it maintains the alignment and stability of the hip joint. However, it is not a specific intervention to prevent DVT, as it does not enhance the blood circulation or prevent the formation of clots.
Choice C reason: Keeping the heels elevated is a useful intervention to prevent pressure ulcers on the heels, as it reduces the friction and shear forces on the skin. However, it is not a relevant intervention to prevent DVT, as it does not affect the venous flow or prevent the clotting of blood.
Choice D reason: Opioid pain medications as ordered are an important intervention to manage the postoperative pain after total hip replacement, as they provide analgesia and sedation. However, they are not a direct intervention to prevent DVT, as they do not influence the blood coagulation or prevent the thrombus formation. In fact, they may increase the risk of DVT by causing respiratory depression, hypotension, and immobility.
Choice E reason: Early ambulation and leg exercises are the most effective interventions to prevent DVT, as they stimulate the contraction of the leg muscles and improve the blood flow in the veins. They also prevent the pooling and clotting of blood in the lower extremities.
Correct Answer is C
Explanation
Choice A reason: Scabies can be cured with prescription medications that kill the mites and their eggs, such as permethrin cream or ivermectin pills. Steroid cream may help to reduce the itching and inflammation, but it does not eliminate the infection.
Choice B reason: Treatment should start as soon as possible after the diagnosis of scabies, but there is no specific time limit of 72 hours. The sooner the treatment begins, the faster the symptoms will improve and the risk of transmission will decrease.
Choice C reason: Washing clothes, towels, and sheets in hot water is an important part of the education for a client with scabies, as it helps to get rid of any mites or eggs that may have been transferred to the fabrics. The items should also be dried in a hot dryer or sealed in a plastic bag for at least 72 hours.
Choice D reason: Reducing intake of refined sugar has no effect on the risk of scabies, as scabies is not caused by dietary factors, but by a parasitic infestation of the skin by the Sarcoptes scabiei mite. The mite is transmitted by direct skin-to-skin contact or by sharing personal items with an infected person.
Choice E reason: Avoiding close contact with others until treated is another key part of the education for a client with scabies, as it helps to prevent the spread of the infection to other people. The client should also inform their household members, sexual partners, and close contacts, as they may need to be treated as well.
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