Reduction of Risk Potential

Question 1

A dull ache in their right calf with a “funny feeling” in the toes

Answer 1

• Action for the nurse:
  instruct the client to remain in bed (to ensure the client is safely situated) before contacting the PHCP to alert them of the assessment findings.
• May indicate impaired circulation, deep vein thrombosis (DVT), thrombophlebitis, or another surgical or post-surgical complication

Question 2

Complications of both cleft lip and cleft palate

Answer 2

• Ear infections (due to the eustachian tube dysfunction)
• Feeding difficulties (harder for these infants to eat with the abnormality in their palate)
• Speech delay (roof of the mouth and lip have spaces that decrease muscle function)

Question 3

Contraindication of Enoxaparin
on a client with a subdural hemorrhage

Answer 3

Enoxaparin would cause anticoagulation, further contributing to the bleeding