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A prenatal client is experiencing calf pain when she walks. Which action is appropriate for the nurse to implement?

A.

Instruct the client to limit walking episodes.

B.

Tell the client that this is normal during pregnancy.

C.

Gather further assessment data

D.

Instruct the client to elevate the legs consistently throughout the day.

Answer and Explanation

The Correct Answer is C

Rationale:

 

A. Limiting walking episodes may reduce discomfort but does not address the underlying issue or potential complications.

 

B. While leg cramps can be common during pregnancy, calf pain could also indicate a more serious condition, such as deep vein thrombosis (DVT), and should not be dismissed as normal without further investigation.

 

C. Gathering further assessment data is crucial to determine the cause of the calf pain, as it may indicate DVT, a potentially life-threatening condition. The nurse should assess for other symptoms like swelling, redness, or warmth in the leg.

 

D. Instructing the client to elevate the legs may be appropriate for general discomfort, but without proper assessment, it may not be the correct intervention if DVT is present.


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Correct Answer is C

Explanation

Rationale:

A. An increase in weight is typically a symptom of untreated or poorly managed hypothyroidism, not a therapeutic response.

B. A decrease in body temperature is associated with hypothyroidism, and an improvement in this condition should result in a normalization of temperature, not a decrease.

C. An increase in energy is a therapeutic response to liothyronine, as hypothyroidism often causes fatigue and low energy levels. Treatment with liothyronine should alleviate these symptoms and restore normal energy levels.

D. A decreased heart rate (bradycardia) is a symptom of hypothyroidism, and effective treatment should normalize the heart rate, not lower it further.

Correct Answer is A

Explanation

Rationale:

A. Slow, steady bubbling in the suction control chamber indicates that the system is functioning correctly. The nurse should continue to monitor the client's respiratory status and the drainage system.

B. Clamping the chest tube is not indicated unless instructed by the healthcare provider, as it could lead to a dangerous buildup of pressure in the pleural space.

C. Checking the suction control outlet on the wall is not necessary if the suction control chamber is already bubbling steadily.

D. Checking the tubing connections for leaks is unnecessary if the bubbling is slow and steady, as this indicates the system is working properly.

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