You are assessing a client's potential for pulmonary emboli. What finding indicates possible deep vein thrombosis?
A) Pain in the feet
B) Inability to dorsiflex
C) Negative Homan's sign
D) Pain in the calf
D
Feedback:
When assessing the client's potential for pulmonary emboli, the nurse tests for a positive Homan's sign. The client lies on his or her back and lifts his or her leg and his or her foot. If the client reports calf pain (positive Homan's sign) during this maneuver, he or she may have a deep vein thrombosis.
You might also like to view...
The nurse is participating in a quantitative research study. Which of the following is a major characteristic of this type of research?
a. Holistic design b. Deductive reasoning c. Complete and broad focus d. Analysis of words and individual interpretation
A calorie count is done to
A. determine if the patient needs to lose weight. B. calculate the protein, carbohydrates, fat, and calories the patient consumes. C. evaluate the patient's fluid intake to evaluate hydration. D. ensure that staff are accurately recording the percentage of each meal consumed.
The nurse instructs the unlicensed assistive personnel to feed an older adult. If the nurse is unable to observe feeding directly, then which action should the nurse use to assess the older adult's risk for aspiration immediately after feeding?
a. Note food volume eaten. c. Inspect for pocket-ing. b. Observe skin color. d. Monitor for bra-dypnea.
The nurse executive is planning education for new nurse managers regarding the AACN Standards for a Healthy Work Environment. Which information should be included?
1. The critical partners in the organization are physicians, members of the administration, and nurse managers. 2. Staff nurses must embrace authentic leadership and value it to ensure an effectively running patient care unit. 3. In critical care units the need for expert clinical skills is more important than simple communication skills. 4. True collaboration must be promoted to ensure a healthy work environment.