A patient with peripheral arterial disease (PAD) reports leg pain while walking which resolves with rest. The nurse recognizes this symptom as:
Deep vein thrombosis
Restless leg syndrome
Intermittent claudication
Varicose veins
The Correct Answer is C
A. Deep vein thrombosis. Deep vein thrombosis typically causes constant pain, swelling, and redness and does not improve with rest.
B. Restless leg syndrome. Restless leg syndrome is characterized by an uncontrollable urge to move the legs, usually at rest, and is not associated with walking.
C. Intermittent claudication. Intermittent claudication is a common symptom of PAD where muscle pain or cramping occurs during activity and is relieved with rest due to insufficient blood flow.
D. Varicose veins. Varicose veins generally cause aching and swelling rather than pain triggered specifically by walking.
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Correct Answer is B
Explanation
A. Keep the patient NPO (nothing by mouth) until the T-tube is removed. Patients are generally kept NPO initially but may resume clear liquids and progress to a regular diet based on tolerance; NPO status is not required until the T-tube is removed.
B. Monitor the tube drainage and document the amount and color. Monitoring and documenting drainage from the T-tube is crucial to assess biliary function and ensure that the bile is draining properly, indicating no obstruction.
C. Ensure the tube is clamped for 8 hours each day. Clamping may be done before tube removal to test the body’s tolerance to bile drainage, but it should be done only as per physician orders, not routinely for 8 hours each day.
D. Flush the T-tube with normal saline every 4 hours. Flushing a T-tube is generally not done routinely as it could disrupt the flow of bile and cause complications.
Correct Answer is A
Explanation
A. Use written communication or visual aids to supplement verbal instructions. Written communication and visual aids are effective ways to enhance understanding and provide clear instructions to a patient with hearing loss.
B. Speak loudly and directly into the patient's ear. Speaking loudly can distort sounds and may make it harder for the patient to understand. Instead, clear and slow speech with normal volume is recommended.
C. Turn off all background noise and speak to the patient from behind. While reducing background noise is beneficial, speaking from behind is ineffective as the patient cannot see the nurse’s facial expressions or read lips.
D. Assume the patient can read lips and avoid using sign language or gestures. Assuming the patient can read lips is not appropriate; gestures or other visual aids should be used to enhance communication.