Asked by jessika stanley on Jul 09, 2024

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Mr.Granger is a 65-year-old client hospitalized with multiple fractures suffered in a motor vehicle accident.He calls the nurse and complains of pain and burning in the right calf area.What action should be taken by the nurse?

A) Percuss over the area for change in tone
B) Deeply palpate the area for rebound tenderness
C) Measure the calf and compare to the opposite calf
D) Medicate the client for pain and reassess in 30 minutes

Rebound Tenderness

A clinical sign indicative of peritonitis, where pain is felt upon the quick release of deep pressure from the abdomen.

Percuss

In the medical context, "percuss" refers to the act of tapping on a surface, typically the body, to diagnose the condition of the underlying tissues or organs.

Palpate

To examine or explore by touching (an organ or area of the body), usually as a diagnostic aid.

  • Identify signs and symptoms of potential complications related to immobility and how to address them.
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MT
Miriam TreviñoJul 15, 2024
Final Answer :
C
Explanation :
The nurse should measure the client's calf and compare it to the opposite calf to assess for any possible swelling, which could indicate deep vein thrombosis (DVT). Pain and burning in one calf can be a symptom of DVT, which is a serious complication that requires immediate attention. Percussing or palpating the area could potentially dislodge a blood clot, so these actions should be avoided. Medicating the client for pain may provide temporary relief, but it does not address the underlying issue and does not provide adequate assessment.