When assessing the patient for risk for DVT, the nurse should consider which of the following an indicator of increased risk?
a. A positive Homans' sign
b. Pallor to the distal area
c. Edema noted in the extremity
d. Fever or dehydration
D
Indicators in Virchow's triad include clotting disorders, fever, and dehydration. Additionally, a swollen extremity, pain, and warm cyanotic skin, indicate an elevated risk. Less than 20% of patients exhibit a positive Homans' sign. Edema of the extremity may or may not occur.
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A home health care nurse is visiting an older client who lives alone after being discharged from the hospital after a coronary artery bypass graft. What finding in the home most causes the nurse to consider additional referrals?
a. Dirty carpets in need of vacuuming b. Expired food in the refrigerator c. Old medications in the kitchen d. Several cats present in the home
A 72-year-old man who is unable to sleep since admission into the hospital is given a hypnotic medication at 9 PM. The nurse finds the patient drowsy and confused at 10 AM the next day. The nurse is aware that this behavior is most likely due to
A) decreased hepatic function. B) a toxic effect. C) an allergic reaction. D) increased renal function.
The nurse is teaching a client with herpes simplex virus (HSV) type 2 appropriate methods to prevent further spread of the virus while lesions are present. The nurse stresses that clients should
a. apply warm soaks to the lesions. b. complete antibiotic therapy. c. maintain separate towels and other personal items. d. stop using condoms because they are irritating.
The nurse is caring for a client after a stroke. The client has a right facial droop, drools continuously, and chokes on her own saliva. What rehabilitation team member should the nurse consult to ensure client safety?
a. Speech-language pathologist b. Nutritionist c. Rehabilitation case manager d. Cognitive therapist