The nurse is caring for a 48-year-old male client who was involved in

The nurse is caring for a 48-year-old male client who was involved in a motor vehicle accident and had a fractured pelvis, a ruptured spleen, and multiple contusions. The client has been in the hospital for 5 days on bed rest.

The nurse knows that this client is at risk for venous thrombus formation because of prolonged bed rest, potential damage to vessel walls during surgery, and the platelets he received in the trauma unit. These three factors are also known as:
1. Trigeminy
2. Virchow’s triad
3. Trigone
4. Hutchinson’s triad

ANSWER

ANS: 2
There are three factors that contribute to venous thrombus formation: (1) damage to the vessel wall (e.g., injury during surgical procedures), (2) alterations of blood flow (e.g., slow blood flow in calf veins associated with bed rest), and (3) alterations in blood constituents (e.g., a change in clotting factors or increased platelet activity. These three factors are sometimes referred to as Virchow’s triad