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 A

Explanation

A. "I will reduce my intake of vitamin K-rich foods."
Vitamin K is essential for bone health as it helps in the regulation of calcium within bones and blood vessels. Therefore, reducing the intake of vitamin K-rich foods would not be beneficial for preventing osteoporosis. In fact, adequate intake of vitamin K is important for bone health.

B. "I will limit my intake of soft drinks." - Soft drinks, especially cola beverages, contain phosphoric acid, which can leach calcium from bones, making them weaker and more susceptible to fractures.

C. "I will reduce my intake of sodium." - High sodium intake can lead to increased calcium excretion in the urine, potentially weakening bones over time. Reducing sodium intake can help in preventing bone loss.

D. "I will decrease my intake of caffeine." - Excessive caffeine consumption can interfere with calcium absorption, contributing to bone loss. Decreasing caffeine intake is advisable for maintaining bone health.

A. Chronic pain B. Impaired skin integrity C. Risk for injury D. Ineffective tissue perfusion

Correct Answer is D

Explanation

A. Chronic pain - Chronic pain is a concern for the client, but addressing the underlying issue of ineffective tissue perfusion will help alleviate pain by promoting healing and reducing tissue damage.

B. Impaired skin integrity - Impaired skin integrity is a result of ineffective tissue perfusion. By addressing perfusion issues, skin integrity can be improved as tissues receive adequate oxygen and nutrients for healing.

C. Risk for injury - While clients with arterial insufficiency ulcers are at risk for injury, the immediate concern is addressing the ineffective tissue perfusion to prevent complications related to poor circulation, such as tissue necrosis and infection.

D. Ineffective tissue perfusion- Arterial insufficiency ulcers are caused by inadequate blood flow to the tissues. The priority issue for a client with an arterial insufficiency ulcer is ineffective tissue perfusion. Due to decreased blood flow, tissues do not receive enough oxygen and nutrients, leading to delayed wound healing, tissue damage, and potential complications. Interventions should focus on improving circulation, promoting vasodilation, and enhancing perfusion to facilitate wound healing and prevent further tissue damage.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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