The nurse is completing an admission assessment on an older adult client with dehydration, failure to thrive, and who is immobile. The nurse reports to the healthcare provider that the client's right calf is red and swollen. The nurse should suspect which probable cause of these findings?
Explanation & Rationale
A. Redness and swelling of the calf are classic signs of deep vein thrombosis (DVT), especially in an older adult who is immobile. DVT is a common complication in hospitalized patients, particularly those who are immobile or have other risk factors such as dehydration. B. Fat emboli typically present with symptoms such as dyspnea, tachypnea, and petechial rash, rather than localized redness and swelling of the calf. C. Pulmonary embolism typically presents with symptoms such as chest pain, dyspnea, tachypnea, and hemoptysis, rather than localized redness and swelling of the calf. D. While infection can cause localized redness and swelling, the presence of dehydration and immobility increases the likelihood of a thrombotic event such as deep vein thrombosis. It is important to consider DVT as a potential cause of these findings and initiate appropriate diagnostic and preventive measures.