Nokea
The nurse is caring for a client with deep venous thrombosis of the lower extremity. Which of the following findings would the nurse expect to observe? Select all that apply.
- A. dry, shiny, hairless skin on the affected extremity
- B. warmth and redness of the affected extremity
- C. reports of pain in the affected calf
- D. edema of the affected extremity
- E. cyanosis of the affected toes
Correct Answer: B,C,D
Rationale: DVT causes inflammation, leading to warmth, redness, pain, and edema in the affected extremity. Dry, shiny, hairless skin and cyanosis are more typical of arterial insufficiency, not DVT.
You may also like to solve these questions
The nurse is caring for a client who will not use the train for transportation due to the fear of being trapped and unable to escape. The nurse should recognize that the client is likely experiencing
- A. generalized anxiety disorder
- B. social anxiety disorder
- C. agoraphobia
- D. acrophobia
Correct Answer: C
Rationale: Fear of being trapped in situations (e.g., trains) with no escape is characteristic of agoraphobia. Generalized anxiety involves broad worries, social anxiety focuses on social scrutiny, and acrophobia is fear of heights.
The nurse is reinforcing education about lifestyle modifications for a client newly diagnosed with Meniere disease. Which statement by the client indicates a need for further teaching?
- A. I need to enroll in a smoking cessation program.
- B. I need to restrict the amount of potassium in my diet.
- C. I will lie down and avoid walking unassisted during acute attacks.
- D. I will limit the amount of caffeine and alcohol that I consume.
Correct Answer: B
Rationale: Restricting potassium isn't indicated for Ménière's disease; a low-sodium diet is typically recommended to reduce fluid retention. Smoking cessation, lying down during attacks, and limiting caffeine/alcohol are appropriate.
The nurse is preparing to administer insulin aspart subcutaneously at 0700 to a client with type 1 diabetes mellitus. Which of following actions would be a priority for the nurse to take?
- A. Choose a site on the clients arm for the injection
- B. Give the client breakfast within 15 minutes
- C. Recheck the capillary blood glucose level in 1 hour
- D. Reinforce teaching about signs and symptoms of hyperglycemia
Correct Answer: B
Rationale: Insulin aspart is rapid-acting, peaking within 1-3 hours. Administering it at 0700 requires breakfast within 15 minutes to prevent hypoglycemia. Site selection is routine, rechecking glucose later is secondary, and teaching is not urgent.
The parents of a 2 year-old child report that he has been holding his breath whenever he has temper tantrums. What is the best action by the nurse?
- A. Teach the parents how to perform cardiopulmonary resuscitation
- B. Recommend that the parents give in when he holds his breath to prevent anoxia
- C. Advise the parents to ignore breath holding because breathing will begin as a reflex
- D. Instruct the parents on how to reason with the child about possible harmful effects
Correct Answer: C
Rationale: Advise the parents to ignore breath holding because breathing will begin as a reflex. Breath-holding is benign and self-resolving in toddlers.
The nurse is talking with the parent of an adolescent client with suspected bulimia nervosa. Which of the following statements by the client's parent would be consistent with bulimia nervosa?
- A. I have noticed my child cuts food into small pieces and pushes it around the plate.
- B. I found several empty boxes of laxatives in my child's bedroom.
- C. My child has lost 20 lb (9.1 kg) in the past 2 months.
- D. My child has stopped exercising.
Correct Answer: B
Rationale: Laxative abuse is a common purging behavior in bulimia nervosa. Cutting food and pushing it around is more typical of anorexia. Significant weight loss is less common in bulimia, as weight often fluctuates. Reduced exercise isn't characteristic.