Nokea
The nurse is caring for a client at risk for thrombosis. What is an appropriate nursing action when evaluating this client?
- A. Examine the client's mental and emotional status
- B. Examine the legs for color, capillary refill time, and tissue integrity
- C. Examine for pain around the shoulder and neck region
- D. Examine the extremities for skin lesions
Correct Answer: B
Rationale: The nurse examines the extremities and assesses skin color, temperature, capillary refill time, and tissue integrity and not for skin lesions for clients with thrombosis. Examining the client's mental and emotional status or examining for pain around the shoulder and neck region will not assist the nurse in evaluating a client with thrombosis.
You may also like to solve these questions
A client is prescribed a nitroglycerin transdermal patch to treat angina. Which statement does the nurse include when reinforcing medication teaching to the client prior to discharge?
- A. You do not need the effects of this medication while you sleep
- B. The medication patch causes headaches so you should remove it daily
- C. The patch should be worn for 12 hours and then removed for 12 hours
- D. Skin irritation is common when the patch is worn for more than 12 hours
Correct Answer: C
Rationale: A transdermal nitroglycerin patch is prescribed for the prevention of angina pectoris. Nitroglycerin transdermal patches are typically applied for 12 to 14 hours, and then removed for the same amount of time. Though it is true that common adverse effects of nitroglycerin are headaches and contact dermatitis and that there is less demand on the heart when the client rests, these are not the reasons for applying and removing the patch for the same length of time in a 24-hour period.
The nurse is caring for a client who is status postoperative from a vein stripping. What would the nurse monitor for in the client?
- A. Swelling in the inoperative leg
- B. Blood on the dressing on the inoperative leg
- C. Warm, pink toes in the inoperative leg
- D. Swelling in the operative leg
Correct Answer: D
Rationale: When the client returns from surgery with a gauze dressing covered by elastic roller bandages on the operative leg, the nurse monitors for swelling in the operative leg(s) and its effect on circulation.
Which assessment finding by the nurse is the most significant finding suggestive of aortic aneurysm?
- A. High blood pressure
- B. Severe back pain
- C. Abdomen bruit
- D. Nausea and vomiting
Correct Answer: C
Rationale: A pulsating mass or a bruit in the abdomen over the mass is most suggestive of aortic aneurysm. Severe back pain, nausea, and high blood pressure are all symptoms associated with aortic aneurysm but not as independently suggestive.
A client with a strong family history of coronary artery disease asks the nurse how to reduce the risk of developing the disorder. Which is the best response by the nurse?
- A. Moderation is the key to everything
- B. Ask your physician to prescribe the new reverse lipid drug
- C. Increase the soy in your diet
- D. Exercise, keep your blood sugar in check, and manage your stress
Correct Answer: D
Rationale: Although moderation is the key, this does not provide specific options for this client such as regular exercise and managing stress and cholesterol levels. The reverse lipid drug sounds good but is not available or approved by the FDA. Soy products have limited benefits for cholesterol control.
The nurse knows that women and older adults are at greater risk for a fatal myocardial event. Which factor is the primary contributor of this cause?
- A. Chest pain is typical
- B. Vague symptoms
- C. Decreased sensation to pain
- D. Gender bias
Correct Answer: B
Rationale: Often, women and older adults do not have the typical chest pain associated with a myocardial infarction. Some report vague symptoms (fatigue, abdominal pain), which can lead to misdiagnosis. Some older adults may experience little or no chest pain. Gender is not a contributing factor for fatal occurrence but rather a result of symptoms association.