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 A
Explanation
A. Right hip dislocation: In a hip dislocation, the head of the femur is forced out of the acetabulum, which is the socket in the pelvis. This can cause a noticeably shorter leg, hip deformity, and acute pain. Imaging might not show a fracture in the case of a dislocation.
B. Right hip contusion: A hip contusion is a bruise on the hip, usually caused by a direct blow or trauma. While it can cause pain and swelling, it typically does not result in a noticeably shorter leg or hip deformity.
C. Right hip strain: Hip strain refers to damage to the muscles or tendons around the hip joint due to overuse or sudden twisting movements. While it can cause pain, it does not typically lead to a noticeable leg shortening or hip deformity.
D. Right hip osteoarthritis: Osteoarthritis is a degenerative joint disease that can affect the hip joint. It leads to joint pain and stiffness but does not usually cause a noticeable leg shortening or acute deformity unless there are severe complications, which are not mentioned in the scenario.
Correct Answer is B
Explanation
A. Provide the client with antipyretic therapy. - Antipyretic therapy can help reduce fever, but addressing the underlying infection with antibiotics is crucial.
B. Administer antibiotics to the client. -The priority intervention for a client with acute osteomyelitis is to administer antibiotics promptly. Osteomyelitis is a severe bacterial infection of the bone, which requires aggressive antibiotic therapy to eradicate the infection. Delaying antibiotic treatment can lead to further complications and the spread of the infection.
C. Teach relaxation breathing to reduce the client's pain. - Pain management is important, but in the case of acute osteomyelitis, the priority is to eliminate the infection through antibiotics.
D. Increase the client's protein intake. - Adequate nutrition, including protein, is important for overall healing and immune function, but it is not the priority when dealing with an acute infection that requires immediate antibiotic treatment.
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