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

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Performing range of motion:
Explanation: Range of motion exercises are important for preventing joint stiffness and muscle atrophy, especially in clients with casts. However, this is not the first priority. Ensuring adequate circulation and perfusion is crucial before initiating any exercises or movements, as compromised circulation could lead to serious complications.

B. Managing pain:
Explanation: Pain management is important for the client's comfort, but it is not the first priority in this context. Assessing circulation and ensuring there are no signs of compromised perfusion takes precedence. Pain management can follow once circulation has been confirmed as adequate.

C. Checking capillary refill:
Explanation: Checking capillary refill is the first priority when assessing a client with a cast. Capillary refill assesses peripheral circulation by pressing on the nail bed and observing how quickly color returns. Delayed capillary refill could indicate compromised blood flow, which is a serious concern and requires immediate intervention.

D. Discussing cast care:
Explanation: Educating the client about cast care is important, but it is not the first priority. Ensuring proper circulation and ruling out any signs of impaired perfusion must be addressed before discussing cast care instructions.

A. "Pyelonephritis increases a person's risk for kidney damage." B. "Pyelonephritis is an infection of the lower urinary tract." C. "Pyelonephritis often causes no symptoms in affected clients." D. "Pyelonephritis is most often caused by Staphylococcus saprophyticus."

Correct Answer is A

Explanation

A. "Pyelonephritis increases a person's risk for kidney damage." - Pyelonephritis is a bacterial infection of the renal parenchyma and renal pelvis, typically caused by the ascent of bacteria from the lower urinary tract into the kidneys. If left untreated, it can lead to kidney damage, including scarring of the renal tissue and impaired kidney function.

B. "Pyelonephritis is an infection of the lower urinary tract." - This statement is incorrect. Pyelonephritis specifically involves the upper urinary tract, affecting the kidneys. In contrast, infections of the lower urinary tract (such as cystitis) affect the bladder and urethra.

C. "Pyelonephritis often causes no symptoms in affected clients." - This statement is incorrect. Pyelonephritis typically presents with symptoms such as fever, chills, flank pain, painful urination (dysuria), and frequent urination. Clients with pyelonephritis usually experience noticeable symptoms.

D. "Pyelonephritis is most often caused by Staphylococcus saprophyticus." - This statement is incorrect. While Staphylococcus saprophyticus is a common cause of urinary tract infections, pyelonephritis is more commonly caused by gram-negative bacteria, such as Escherichia coli, which often ascend from the lower urinary tract into the kidneys.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has a cast in place for a fractured tibia. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

A nurse is teaching a group of nursing students about pyelonephritis. Which of the following statements should the nurse include in the teaching?

Correct Answer is A

Explanation

A nurse educator is providing an in-service to nursing staff about urinary tract infections (UTP). Which statements made by the staff validate they understand the etiology and pathophysiology of UTIs? Select all that apply.

A provider orders a diagnostic test for a client with a urinary tract infection. The test will determine the strain of bacteria causing the infection and determine the antibiotic that will treat the infection. The nurse knows this test is called which of the following?

A nurse is caring for a client who has urinary incontinence. Which of the following actions should the nurse implement to prevent the development of skin breakdown?

A nurse is caring for a client who is malnourished with poor skin integrity. The nurse should utilize which type of dressing to protect the client's bony prominences?

A nurse is assessing an older adult client who has osteoporosis. Which of the following spinal deformities should the nurse expect to find in this client?

A nurse is caring for a client with acute pyelonephritis. Which area should the nurse percuss to assess for pain related to pyelonephritis?