Nokea
During a routine prenatal visit, a client in her third trimester of pregnancy reports having frequent calf pain when she walks. The nurse suspects superficial thrombophlebitis and checks for which sign associated with this condition?
- A. Severe chills
- B. Kernig's sign
- C. Brudzinski's sign
- D. Palpable hard thrombus
Correct Answer: D
Rationale: Pain in the calf during walking could indicate venous thrombosis or peripheral arterial disease. The manifestations of superficial thrombophlebitis include a palpable thrombus that feels bumpy and hard, tenderness and pain in the affected lower extremity, and a warm and pinkish red color over the thrombus area. Severe chills can occur in a variety of inflammatory or infectious conditions and are also a manifestation of pelvic thrombophlebitis. Brudzinski's sign and Kernig's sign test for meningeal irritability.
You may also like to solve these questions
The nurse is analyzing an electrocardiogram (ECG) rhythm strip on an assigned client. What should the nurse record as the client's PR interval?
- A. 0.12 second
- B. 0.20 second
- C. 0.24 second
- D. 0.40 second
Correct Answer: A
Rationale: Standard ECG graph paper measurements are 0.04 second for each small box on the horizontal axis (measuring time) and 1 mm (measuring voltage) for each small box on the vertical axis.
A child is admitted to the hospital with a diagnosis of nephrotic syndrome. The nurse expects to note documentation of which manifestation in the medical record? Select all that apply.
- A. Edema
- B. Proteinuria
- C. Hypertension
- D. Abdominal pain
- E. Increased weight
- F. Hypoalbuminemia
Correct Answer: A,B,D,E,F
Rationale: Nephrotic syndrome refers to a kidney disorder characterized by edema, proteinuria, and hypoalbuminemia. The child also experiences anorexia, fatigue, abdominal pain, respiratory infection, and increased weight. The child's blood pressure is usually normal or slightly below normal.
The nurse is admitting a client with a diagnosis of hypothyroidism. What assessment should the nurse perform to obtain data related to this diagnosis?
- A. Inspect facial features.
- B. Auscultate lung sounds.
- C. Percuss the thyroid gland.
- D. Inspect ability to ambulate safely.
Correct Answer: A
Rationale: Inspection of facial features will reveal the characteristic coarse features, presence of edema around the eyes and face, and the blank expression that are characteristics of hypothyroidism. The assessment techniques in options 2, 3, and 4 will not reveal information related to the diagnosis of hypothyroidism.
On assessment of a newborn being admitted to the nursery, the nurse palpates the anterior fontanel and notes that it feels soft. The nurse determines that this finding indicates which condition?
- A. Dehydration
- B. A normal finding
- C. Increased intracranial pressure
- D. Decreased intracranial pressure
Correct Answer: B
Rationale: The anterior fontanel is normally 2 to 3 cm in width, 3 to 4 cm in length, and diamond-like in shape. It can be described as soft, which is normal, or full and bulging, which could indicate increased intracranial pressure. Conversely a depressed fontanel could mean that the infant is dehydrated.
The nurse who practices culturally sensitive nursing care incorporates which concepts into client care? Select all that apply.
- A. The expression of pain is affected by learned behaviors.
- B. Physiologically, all individuals experience pain in a similar manner.
- C. Ethnic culture has an effect on the physiological response to pain medications.
- D. Clients should be assessed for pain regardless of a lack of overt symptomatology.
- E. The use of a standardized pain assessment tool ensures unbiased pain assessment.
Correct Answer: A,C,D
Rationale: Pain and its expression are often affected by an individual's ethnic culture in ways that include learned means of pain expression, the physiological response to pain medications, and attitudes regarding acceptable ways of dealing with pain. Physiologically not all individuals, even those of the same ethnic culture, will respond to pain in a similar manner, and so a standardized pain assessment tool is not effective in measuring pain in all clients.