A 74-year-old obese man who has undergone open reduction and internal fixation of the right hip is 8 days postoperative. He has a history of arthritis and atrial fibrillation. He admits to right lower leg pain, described as "a cramp in my leg." An appropriate nursing action is to:
Answer(s): B
(A) Calf pain with dorsiflexion of the foot (Homans' sign) can be a sign of a deep venous thrombosis; however, it is not diagnostic of the condition. (B) Swelling and warmth along the affected vein are commonly observed clinical manifestations of a deep venous thrombosis as a result of inflammation of the vessel wall. (C) Rubbing or massaging of the affected leg is contraindicated because of the risk of the clot breaking loose and becoming an embolus. (D) A pillow behind the knee can be constricting and further impair blood flow.
A gravida 2 para 1 client is hospitalized with severe preeclampsia. While she receives magnesium sulfate(MgSO4) therapy, the nurse knows it is safe to repeat the dosage if:
Answer(s): D
(A) MgSO4is a central nervous system depressant. Loss of reflexes is often the first sign of developing toxicity. (B) Urinary output at <25 mL/hr or 100 mL in 4 hours may result in the accumulation of toxic levels of magnesium. (C) The therapeutic serum range for MgSO4is 68 mg/dL. Higher levels indicate toxicity. (D) Respirations of>16 breaths/min indicate that toxic levels of magnesium have not been reached. Medication administration would be safe.
Assessment of severe depression in a client reveals feelings of hopelessness, worthlessness; inability to feel pleasure; sleep, psychomotor, and nutritional alterations; delusional thinking; negative view of self; and feelings of abandonment. These clinical features of the client's depression alert the nurse to prioritize problems and care by addressing which of the following problems first:
Answer(s): C
(A) Anorexia and weight loss are problems that need attention in severe depression, but they can be addressed secondary to immediate concerns. (B) Impaired thinking and confusion are problems in severe depression that are addressed with administration of medication, through group and individual psychotherapy, and through activity therapy as motivation and interest increase. (C) Possible harm to self as with suicidal ideation; a suicide plan, means to execute plan; and/or overt gestures or an attempt must be addressed as an immediate concern and safety measures implemented appropriate to the risk of suicide. (D) Rest and activity impairment may take time and further assessment to determine client's sleep pattern and amount of psychomotor retardation with the more immediate concern for safety present.
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