A prenatal client is experiencing calf pain when she walks. Which action is appropriate for the nurse to implement?
Instruct the client to limit walking episodes.
Tell the client that this is normal during pregnancy.
Gather further assessment data
Instruct the client to elevate the legs consistently throughout the day.
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 B
Explanation
Rationale:
A. Popping sounds, also known as crackles, are typically associated with fluid in the alveoli, often seen in conditions like pneumonia or heart failure, not pleurisy.
B. Loud, grating sounds, known as pleural friction rub, are characteristic of pleurisy. This sound is produced by the inflamed pleural surfaces rubbing together during respiration.
C. Snoring sounds, or rhonchi, are usually heard in conditions involving airway obstruction by mucus, such as bronchitis, rather than pleurisy.
D. Squeaky, musical sounds, or wheezing, are associated with airway narrowing, such as in asthma or chronic obstructive pulmonary disease (COPD), and are not typically heard in pleurisy.
Correct Answer is A
Explanation
Rationale:
A. Injecting insulin into the abdominal area is appropriate as it is one of the preferred sites for insulin administration due to its consistent absorption.
B. Blood sugar readings should be taken before meals, not after, to determine the need for insulin and to manage blood glucose levels effectively.
C. Insulin does not allow for unrestricted consumption of high-sugar foods like ice cream; instead, a balanced diet is important to maintain stable blood glucose levels.
D. While weight reduction can help manage diabetes, it does not inherently cause hypoglycemia unless the client is taking insulin or other medications that lower blood glucose.