The best approach for the nurse to use to assess the presence of thrombosis in an immobilized client is to:
A. Measure the calf and thigh diameters
B. Attempt to elicit Homans' sign
C. Palpate the temperature of the feet
D. Observe for a loss of hair and skin turgor in the lower legs
A
A. Calf and thigh circumference should be measured daily. Unilateral increases in calf or thigh diameter can be an early indication of thrombosis.
B. Homans' sign is not always positive in the presence of thrombosis.
C. Assessing the temperature of the feet is not the best approach to determine the presence of thrombosis.
D. Observing for hair loss and skin turgor of the lower legs is not the best approach to determine the presence of thrombosis. A lack of hair may indicate a chronic lack of oxygen. Skin turgor is a measure of hydration.
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