Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is collecting data from a client who is 1 day postoperative following a total hip arthroplasty and has
deep-vein thrombosis. Which of the following findings should the nurse expect in the affected extremity?
A. Absent dorsal pedal pulse
An absent dorsal pedal pulse would indicate a vascular problem such as arterial occlusion, not a deep vein thrombosis (DVT). In the case of DVT, blood flow in the veins is obstructed, but the arterial pulse, which is related to arterial circulation, should remain intact unless there is a separate arterial issue. Therefore, absent pulses are not characteristic of DVT.
B. Shiny, hairless skin
Shiny, hairless skin is a sign typically associated with chronic arterial insufficiency, not DVT. This skin change occurs when there is poor arterial blood flow, which leads to a lack of nourishment for the skin, causing it to become thin and shiny. In contrast, DVT affects the veins and does not usually cause these skin changes in the acute phase.
C. Irregular, bulging veins
Irregular, bulging veins are indicative of varicose veins or chronic venous insufficiency, not a DVT. Varicose veins occur when the veins become swollen and twisted due to weak or damaged valves. DVT, on the other hand, involves the formation of a clot in the deep veins and does not typically cause the veins to bulge visibly, especially in the early stages.
D. Dull, aching pain
Dull, aching pain is a common symptom associated with deep vein thrombosis. This pain typically occurs in the affected extremity and is often described as a constant, aching sensation. The pain can worsen with movement or standing and is due to the inflammation and obstruction caused by the blood clot in the deep veins. This is a hallmark sign of DVT, along with swelling and redness in the affected limb.
This question is an excerpt from Nurse Dive's nursing test bank - VATI PN Comprehensive Predictor 2020 Proctored Exam. Take the full exam now
Full Explanation
Choice A:
An absent dorsal pedal pulse would indicate a vascular problem such as arterial occlusion, not a deep vein thrombosis (DVT). In the case of DVT, blood flow in the veins is obstructed, but the arterial pulse, which is related to arterial circulation, should remain intact unless there is a separate arterial issue. Therefore, absent pulses are not characteristic of DVT.
Choice B:
Shiny, hairless skin is a sign typically associated with chronic arterial insufficiency, not DVT. This skin change occurs when there is poor arterial blood flow, which leads to a lack of nourishment for the skin, causing it to become thin and shiny. In contrast, DVT affects the veins and does not usually cause these skin changes in the acute phase.
Choice C:
Irregular, bulging veins are indicative of varicose veins or chronic venous insufficiency, not a DVT. Varicose veins occur when the veins become swollen and twisted due to weak or damaged valves. DVT, on the other hand, involves the formation of a clot in the deep veins and does not typically cause the veins to bulge visibly, especially in the early stages.
Choice D:
Dull, aching pain is a common symptom associated with deep vein thrombosis. This pain typically occurs in the affected extremity and is often described as a constant, aching sensation. The pain can worsen with movement or standing and is due to the inflammation and obstruction caused by the blood clot in the deep veins. This is a hallmark sign of DVT, along with swelling and redness in the affected limb.
Similar Questions
A nurse is collecting data for a client following electroconvulsive therapy. Which of the following adverse effects should the nurse expect?
A. Vomiting
Vomitingis not a typical adverse effect of electroconvulsive therapy.
B. Confusion
A nurse collecting data for a client following electroconvulsive therapy should expect that the client may experience confusion as an adverse effect. Confusion is a common side effect of electroconvulsive therapy and can last for minutes to hours after treatment.
C. Incontinence
Incontinence is not a typical adverse effect of electroconvulsive therapy.
D. Tinnitus
Tinnitusis not a typical adverse effect of electroconvulsive therapy.
Full Explanation
A nurse collecting data for a client following electroconvulsive therapy should expect that the client may experience confusion as an adverse effect. Confusion is a common side effect of electroconvulsive therapy and can last for minutes to hours after treatment.
The other options are not typical adverse effects of electroconvulsive therapy.
a) Vomiting is not a typical adverse effect of electroconvulsive therapy.
c) Incontinence is not a typical adverse effect of electroconvulsive therapy.
d) Tinnitus is not a typical adverse effect of electroconvulsive therapy.
A nurse is reinforcing teaching with a client about smoking cessation.
Which of the following client statements indicates an understanding of the teaching?
A. "I can continue to smoke while using nicotine patches."
Using nicotine patches does not allow for continued smoking as it delivers nicotine without the harmful effects of smoking.
B. "I should join a support group to help me be successful."
Joining a support group is a beneficial strategy for quitting smoking as it provides social support, encouragement, and shared experiences with others who are also trying to quit.
C. "Nicotine replacement therapy can cause cancer."
Nicotine replacement therapy (NRT) is a safe and effective method to manage nicotine withdrawal and does not cause cancer.
D. "Varenicline could make me addicted to nicotine."
Varenicline is a medication that helps reduce nicotine cravings and withdrawal symptoms, and it does not make a person addicted to nicotine.
Full Explanation
b. "I should join a support group to help me be successful."
The statement that indicates an understanding of smoking cessation teaching is option b: "I should join a support group to help me be successful." Joining a support group is a beneficial strategy for quitting smoking as it provides social support, encouragement, and shared experiences with others who are also trying to quit.
Option a is incorrect because using nicotine patches does not allow for continued smoking as it delivers nicotine without the harmful effects of smoking.
Option c is incorrect because nicotine replacement therapy (NRT) is a safe and effective method to manage nicotine withdrawal and does not cause cancer.
Option d is incorrect because varenicline is a medication that helps reduce nicotine cravings and withdrawal symptoms, and it does not make a person addicted to nicotine.
A nurse is caring for a client who was recently admited to an inpatient mental health unit. The client tells the nurse that he is not coming out of his room anymore because other clients on the unit make fun of him. Which of the following responses by the nurse is appropriate?
A. I think you should just ignore the others
I think you should just ignore the others." This response dismisses the client's concerns and does not address the underlying issue of the client feeling hurt by the interactions with others. It is important for the nurse to address the client's feelings and provide support.
B. You feel upset by the responses of others
The appropriate response by the nurse is to acknowledge and validate the client's feelings. Option b, "You feel upset by the responses of others," demonstrates empathy and reflects back the client's feelings, indicating that the nurse understands and acknowledges the client's distress.
C. Let's keep the focus of our discussion on your needs
Let's keep the focus of our discussion on your needs." While it is important to address the client's needs, it is also necessary to address the client's concerns and feelings related to the interactions with other clients. Ignoring or dismissing the client's concerns can further isolate the client and hinder their progress in the therapeutic environment
D. Everything will get beter once you get to know everyone.
Everything will get beter once you get to know everyone." This response minimizes the client's feelings and does not provide immediate support or address the client's concerns. It is essential for the nurse to validate the client's emotions and explore strategies to address the issue of others making fun of the client.
Full Explanation
b. "You feel upset by the responses of others."
The appropriate response by the nurse is to acknowledge and validate the client's feelings. Option b, "You feel upset by the responses of others," demonstrates empathy and reflects back the client's feelings, indicating that the nurse understands and acknowledges the client's distress.
Explanation for the other options:
a. "I think you should just ignore the others." This response dismisses the client's concerns and does not address the underlying issue of the client feeling hurt by the interactions with others. It is important for the nurse to address the client's feelings and provide support.
c. "Let's keep the focus of our discussion on your needs." While it is important to address the client's needs, it is also necessary to address the client's concerns and feelings related to the interactions with other clients. Ignoring or dismissing the client's concerns can further isolate the client and hinder their progress in the therapeutic environment.
d. "Everything will get beter once you get to know everyone." This response minimizes the client's feelings and does not provide immediate support or address the client's concerns. It is essential for the nurse to validate the client's emotions and explore strategies to address the issue of others making fun of the client.
In summary, the nurse should choose a response that acknowledges the client's feelings and demonstrates empathy. Validating the client's experience can help establish trust and provide a foundation for further therapeutic interventions.