Question

The nusse is checking Homan's sign on a client suspected of having a venous thrombosis. Which action should the nurse take? A. Flex the client's hip and the knee B. Flex the client's hip while extending the knee C. Ask the client to point the toes while bending the knee D. Push the client's foot forward toward the knee while maintaining the knee in extension

Short answer

D. Push the client's foot forward toward the knee while maintaining the knee in extension.

Step-by-step solution

Understand Homan's Sign Test

Homan's sign is a clinical test used to diagnose deep vein thrombosis (DVT). It involves the dorsiflexion of the foot to check for pain in the calf.

Identify the Correct Action

The nurse should flex the foot of the client briskly while their knee remains straightened (in extension) to check for pain in the calf.

Match to Given Options

Among the given choices, identify the option that matches the description of the Homan's sign test.

Select the Correct Answer

Option D describes the correct procedure: 'Push the client's foot forward toward the knee while maintaining the knee in extension.'

Key concepts

Deep Vein Thrombosis Diagnosis

Deep vein thrombosis (DVT) is a condition involving the formation of a blood clot in a deep vein, usually in the legs. It is crucial to diagnose DVT early as it can lead to serious complications like pulmonary embolism. Major symptoms to look for include swelling, pain, and redness in the affected area. There are several methods for diagnosing DVT, including:

• Physical examination: Looking for symptoms and performing tests such as Homan's sign.
• Ultrasound: A commonly used imaging method to detect clots.
• D-dimer test: A blood test that helps to rule out the presence of an abnormal blood clot.
• Venography: An X-ray test where dye is injected to visualize veins.

Early diagnosis and treatment are vital to prevent complications and improve outcomes.

Clinical Nursing Procedures

Clinical nursing procedures are essential for ensuring patient safety and effective care. These procedures cover a wide range of actions including:

• Patient assessment: Gathering and interpreting data related to the patient's health.
• Performing diagnostic tests: Administering tests like the Homan's sign test for DVT detection.
• Medication administration: Ensuring the correct dosages and timings.
• Wound care: Properly cleaning and dressing wounds to prevent infection.

Each procedure must be carried out meticulously to provide the best care for patients. It's important for nurses to stay updated with best practices and guidelines to ensure high-quality care.

Venous Thrombosis Assessment

Venous thrombosis assessment involves evaluating a patient for the presence of blood clots in the veins. This includes:

• Reviewing patient history: Checking for risk factors like recent surgery, prolonged immobility, or clotting disorders.
• Physical examination: Looking for signs like swelling, pain, or redness. Tests like Homan's sign can be indicative of DVT.
• Imaging studies: Ultrasounds or venographies to visualize clots.
• Blood tests: Related to clotting disorders, e.g., D-dimer test.

Effective assessment allows for timely intervention, reducing the risk of complications such as pulmonary embolism.