The triage nurse in the emergency department is assessing a client who reports pain and swelling in the right lower leg. The client's pain became much worse last night and appeared along with fever, chills, and sweating. The client states, "I hit my leg on the car door 4 or 5 days ago, and the sore is getting bigger" The client has a history of diabetes mellitus type 2. Which condition should the nurse anticipate for this client?
Venous thromboembolism (VTE)
Cellulitis
Arterial insufficiency
Thrombocytopenia
The Correct Answer is B
A. Venous thromboembolism (VTE) - While VTE can cause leg pain and swelling, the presence of fever, chills, and localized trauma history in this scenario points more toward cellulitis.
B. Cellulitis
The client's symptoms, including pain, swelling, fever, chills, and sweating, are indicative of cellulitis, which is a bacterial skin infection. The history of trauma to the leg (hitting the leg on the car door) could have introduced bacteria into the skin, leading to the infection. The client's diabetes mellitus type 2 also increases the risk of developing skin infections due to impaired immune function and circulation. Cellulitis often presents with localized pain, swelling, warmth, redness, and systemic symptoms like fever and chills. Immediate medical evaluation and appropriate antibiotic treatment are necessary for cellulitis.
C. Arterial insufficiency - Arterial insufficiency typically presents with symptoms like intermittent claudication, rest pain, and non-healing wounds due to poor circulation. The symptoms described in the scenario are more consistent with an acute infection (cellulitis) rather than chronic arterial insufficiency.
D. Thrombocytopenia - Thrombocytopenia is a condition characterized by low platelet count and does not directly cause localized pain, swelling, and redness in the leg as described in the scenario.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "I will reduce my intake of sodium." - This statement is correct. High sodium intake can lead to increased calcium excretion through the urine, which can weaken bones. Reducing sodium intake can help prevent osteoporosis.
B. "I will limit my intake of soft drinks." - This statement is correct. Soft drinks, especially cola beverages, contain phosphoric acid, which can leach calcium from bones, leading to decreased bone density. Limiting soft drink consumption is advisable for bone health.
C. "I will decrease my intake of caffeine." - This statement is correct. Excessive caffeine consumption can interfere with calcium absorption and increase calcium excretion. It is advisable to limit caffeine intake to prevent osteoporosis.
D. "I will reduce my intake of vitamin K-rich foods." - This statement is incorrect. Vitamin K is essential for bone health as it helps in bone mineralization and reduces the risk of fractures. Foods rich in vitamin K, such as leafy green vegetables, are beneficial for bone health and should not be reduced unless there are specific medical reasons to do so.
Correct Answer is A
Explanation
A. Apply a moisture barrier ointment to the client's skin
Applying a moisture barrier ointment creates a protective barrier on the skin, preventing prolonged exposure to moisture, which can lead to skin breakdown in individuals with urinary incontinence. Keeping the skin dry and protected is essential in preventing skin irritation and breakdown.
B. Check the client's skin every 8 hr for signs of breakdown - Skin should be assessed more frequently, ideally every 2-4 hours, especially in clients with urinary incontinence, to detect signs of breakdown early.
C. Clean the client's skin and perineum with hot water after each episode of incontinence - Hot water can be harsh on the skin and exacerbate irritation. It's recommended to use mild, warm water and gentle cleansing techniques. Harsh cleaning methods can damage the skin.
D. Request a prescription for the insertion of an indwelling urinary catheter - Indwelling urinary catheters pose an increased risk of infection and other complications. Catheters should only be used when absolutely necessary, and preventive measures should be taken to manage incontinence without catheterization whenever possible.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.