Chapter 26- Prep U

A client is diagnosed with a large thoracic aneurysm. Which findings will the nurse expect when assessing this client? Select all that apply. A. Stridor B. Reduced radial pulses C. Brassy cough D. Hoarse voice E. Aphonia

A. Stridor C. Brassy cough D. Hoarse voice E. Aphonia Rationale: The thoracic area is the most common site for a dissecting aneurysm. Symptoms vary and depend on how rapid the aneurysm dilates and how the pulsating mass affects surrounding structures. Symptoms of this type of aneurysm include stridor caused by pressure of the aneurysm against the trachea. Other symptoms include a hoarse voice, a brassy cough, and aphonia (or loss of voice) caused by pressure on the laryngeal nerve. A thoracic aneurysm does not affect pulses in the arms.

When administering heparin anticoagulant therapy, the nurse needs to make certain that the activated partial thromboplastin time (aPTT) is within the therapeutic range of: A. 1.5 to 2.5 times the baseline control. B. 3.5 times the baseline control. C. 4.5 times the baseline control. D. 2.5 to 3.0 times the baseline control.

A. 1.5 to 2.5 times the baseline control. Rationale: A normal PTT level is 21 to 35 seconds. A reading of more than 100 seconds indicates a significant risk of hemorrhage.

The nurse is assessing a client with severe hypertension. Which symptom indicates to the nurse that the client is experiencing dissection of the aorta? A. A ripping sensation in the chest B. Numbness and pain of the left arm C. Pain when flexing the neck forward D. Gradual onset of a frontal headache

A. A ripping sensation in the chest Rationale: Aortic dissections are commonly associated with poorly controlled hypertension. Dissection is caused by rupture in the intimal layer. A rupture may occur through adventitia or into the lumen through the intima, allowing blood to reenter the main channel and resulting in chronic dissection or occlusion of branches of the aorta. The onset of symptoms is usually sudden and described as severe, persistent pain that feels like tearing or ripping. An aortic dissection does not cause pain and numbness of the left arm. Pain when flexing the neck forward is not associated with an aortic dissection. An aortic dissection does not cause a headache.

Which is a characteristic of arterial insufficiency? A. Diminished or absent pulses B. Aching, cramping pain C. Pulses are present but may be difficult to palpate D. Superficial ulcer

A. Diminished or absent pulses Rationale: A diminished or absent pulse is a characteristic of arterial insufficiency. Venous characteristics include superficial ulcer formation, an aching and cramping pain, and presence of pulses.

Which statement is accurate regarding Raynaud disease? A. Episodes may be triggered by unusual sensitivity to cold. B. The disease generally affects the client trilaterally. C. It affects more than two digits on each hand or foot. D. It is most common in men 16 to 40 years of age.

A. Episodes may be triggered by unusual sensitivity to cold. Rationale: Episodes of Raynaud disease may be triggered by emotional factors or by unusual sensitivity to cold. The disease is most common in women between 16 and 40 years of age. It is generally unilateral and affects only one or two digits.

Which sign or symptom suggests that a client's abdominal aortic aneurysm is extending? A. Increased abdominal and back pain B. Retrosternal back pain radiating to the left arm C. Decreased pulse rate and blood pressure D. Elevated blood pressure and rapid respirations

A. Increased abdominal and back pain Rationale: Pain in the abdomen and back signify that the aneurysm is pressing downward on the lumbar nerve root and is causing more pain. The pulse rate would increase with aneurysm extension. Chest pain radiating down the arm would indicate myocardial infarction. Blood pressure would decrease with aneurysm extension, and the respiratory rate may not be affected.

A nurse is caring for a client following an arterial vascular bypass graft in the leg. What should the nurse plan to assess over the next 24 hours? A. Peripheral pulses every 15 minutes after surgery B. Color of the leg every 4 hours C. Ankle-arm indices every 12 hours D. Blood pressure every 2 hours

A. Peripheral pulses every 15 minutes after surgery Rationale: The primary objective in the postoperative period is to maintain adequate circulation through the arterial repair. Pulses, Doppler assessment, color and temperature, capillary refill, and sensory and motor function of the affected extremity are checked and compared with those of the other extremity; these values are recorded initially every 15 minutes and then at progressively longer intervals if the client's status remains stable.

What symptoms should the nurse assess for in a client with lymphedema as a result of impaired nutrition to the tissue? A. Ulcers and infection in the edematous area B. Loose and wrinkled skin C. Cyanosis D. Evident scarring

A. Ulcers and infection in the edematous area Rationale: In a client with lymphedema, the tissue nutrition is impaired because of the stagnation of lymphatic fluid, leading to ulcers and infection in the edematous area. Later, the skin also appears thickened, rough, and discolored. Scarring does not occur in clients with lymphedema. Cyanosis is a bluish discoloration of the skin and mucous membranes.

Heparin therapy is usually considered therapeutic when the activated partial thromboplastin time (aPTT) is how many times higher than a normal value? A. 0.5 to 1.5 B. 1.5 to 2.5 C. 2.5 to 3.5 D. 3.5 to 4.5

B. 1.5 to 2.5 Rationale: Heparin therapy is usually considered therapeutic when the aPTT is 1.5 to 2.5 times the normal aPTT value. The other values are not within therapeutic range.

Which of the following is a diagnostic test that involves injection of a contrast media into the venous system through a dorsal vein in the foot? A. Lymphoscintigraphy B. Contrast phlebography C. Air plethysmography D. Lymphangiography

B. Contrast phlebography Rationale: When a thrombus exists, an X-ray image will disclose an unfilled segment of a vein. Air plethysmography quantifies venous reflux and calf muscle pump ejection. In lymphangiography, contrast media are injected into the lymph system. In lymphoscintigraphy, a radioactive-labeled colloid is injected into the lymph system.

The nurse assessing a client who has arterial insufficiency of the legs and an ulcer on the left great toe would expect to find which characteristic? A. Pulses that are present but difficult to palpate B. Diminished or absent pulses C. Aching, cramping pain D. Superficial ulcer

B. Diminished or absent pulses Rationale: Occlusive arterial disease impairs blood flow and can reduce or obliterate palpable pulsations in the extremities. A diminished or absent pulse is a characteristic of arterial insufficiency.

A patient who had a colon resection 3 days ago is complaining of discomfort in the left calf. How should the nurse assess Homan's sign to determine if the patient may have a thrombus formation in the leg? A. Elevate the patient's legs for 20 minutes and then lower them slowly while checking for areas of inadequate blood return. B. Dorsiflex the foot while the leg is elevated to check for calf pain. C. Extend the leg, plantar flex the foot, and check for the patency of the dorsalis pedis pulse. D. Lower the patient's legs and massage the calf muscles to note any areas of tenderness.

B. Dorsiflex the foot while the leg is elevated to check for calf pain. Rationale: Homan's sign is indicated by pain in the calf after the foot is sharply dorsiflexed.

A client is diagnosed with deep vein thrombosis (DVT). Which nursing diagnosis should receive highest priority at this time? A. Excess fluid volume related to peripheral vascular disease B. Ineffective peripheral tissue perfusion related to venous congestion C. Impaired gas exchange related to increased blood flow D. Risk for injury related to edema

B. Ineffective peripheral tissue perfusion related to venous congestion Rationale: Ineffective peripheral tissue perfusion related to venous congestion takes highest priority because venous inflammation and clot formation impede blood flow in a client with DVT. Impaired gas exchange related to increased blood flow is incorrect because impaired gas exchange is related to decreased, not increased, blood flow. Excess fluid volume related to peripheral vascular disease is inappropriate because there's no evidence that this client has an excess fluid volume. Risk for injury related to edema may be warranted but is secondary to ineffective tissue perfusion.

A nurse is completing an assessment on a client and discovers an enlarged, red, and tender lymph node. The nurse will describe and document the lymph node using which term? A. Lymphangitis B. Lymphadenitis C. Lymphedema D. Elephantiasis

B. Lymphadenitis Rationale: Acute lymphadenitis is demonstrated by enlarged, red, and tender lymph nodes. Lymphangitis is acute inflammation of the lymphatic channels. Lymphedema is demonstrated by swelling of tissues in the extremities because of an increased quantity of lymph that results from an obstruction of lymphatic vessels. Elephantiasis refers to a condition in which chronic swelling of the extremity recedes only slightly with elevation.

A nurse is assessing a client's right lower leg, which is wrapped with an elastic bandage. Which signs and symptoms suggest circulatory impairment? A. Numbness, warm skin temperature, and redness B. Numbness, cool skin temperature, and pallor C. Redness, cool skin temperature, and swelling D. Swelling, warm skin temperature, and drainage

B. Numbness, cool skin temperature, and pallor Rationale: Signs and symptoms of impaired circulation include numbness and cool, pale skin. Signs of localized infection may include swelling, drainage, redness, and warm skin. Signs of adequate circulation include normal sensation and warm skin with normal return of skin color after blanching.

A nurse is instructing a client about using antiembolism stockings. Antiembolism stockings help prevent deep vein thrombosis (DVT) by: A. providing warmth to the extremity. B. forcing blood into the deep venous system. C. elevating the extremity to prevent pooling of blood. D. encouraging ambulation to prevent pooling of blood.

B. forcing blood into the deep venous system. Rationale: Antiembolism stockings prevent DVT by forcing blood into the deep venous system, instead of allowing blood to pool. Ambulation prevents blood from pooling and prevents DVT, but encouraging ambulation isn't a function of the stockings. Antiembolism stockings could possibly provide warmth, but this factor isn't how they prevent DVT. Elevating the extremity decreases edema but doesn't prevent DVT.

A client with systemic lupus erythematosus (SLE) complains that his hands become pale, blue, and painful when exposed to the cold. What disease should the nurse cite as an explanation for these signs and symptoms? A. Buerger's disease B. Raynaud's disease C. Arterial occlusive diseases D. Peripheral vascular disease

B. Raynaud's disease Rationale: Raynaud's disease results from reduced blood flow to the extremities when exposed to cold or stress. It's commonly associated with connective tissue disorders such as SLE. Signs and symptoms include pallor, coldness, numbness, throbbing pain, and cyanosis. Peripheral vascular disease results from a reduced blood supply to the tissues. It occurs in the arterial or venous system. Build-up of plaque in the vessels or changes in the vessels results in reduced blood flow, causing pain, edema, and hair loss in the affected extremity. Arterial occlusive disease is the obstruction or narrowing of the lumen of the aorta and its major branches that interrupts blood flow to the legs and feet, causing pain and coolness. Buerger's disease is an inflammatory, nonatheromatous occlusive disease that causes segmental lesions and subsequent thrombus formation in arteries, resulting in decreased blood flow to the feet and legs.

A physician admits a client to the health care facility for treatment of an abdominal aortic aneurysm. When planning this client's care, which goal should the nurse keep in mind as she formulates interventions? A. Decreasing blood pressure and increasing mobility B. Stabilizing heart rate and blood pressure and easing anxiety C. Increasing blood pressure and monitoring fluid intake and output D. Increasing blood pressure and reducing mobility

B. Stabilizing heart rate and blood pressure and easing anxiety Rationale: For a client with an aneurysm, nursing interventions focus on preventing aneurysm rupture by stabilizing heart rate and blood pressure. Easing anxiety also is important because anxiety and increased stimulation may raise the heart rate and boost blood pressure, precipitating aneurysm rupture. The client with an abdominal aortic aneurysm is typically hypertensive, so the nurse should take measures to lower blood pressure, such as administering antihypertensive agents, as ordered, to prevent aneurysm rupture. To sustain major organ perfusion, the client should maintain a mean arterial pressure of at least 60 mm Hg. Although the nurse must assess each client's mobility individually, most clients need bed rest when initially attempting to gain stability.

A home health nurse is seeing an elderly female client for the first time. During the physical assessment of the client's feet, the nurse notes several circular ulcers around the tips of the toes on both feet. The bases of the ulcers are pale, and the client reports the ulcers to be very painful. From these assessment findings, the nurse suspects that the cause of the ulcers is which of the following? A. Neither venous nor arterial B. Trauma C. Arterial insufficiency D. Venous insufficiency

C. Arterial insufficiency Rationale: Characteristics of arterial insufficiency ulcers include location at the tips of the toes, extreme painfulness, and circular shape with pale to black ulcer bases. Ulcers caused by venous insufficiency will be irregular in shape, minimal pain if superficial (can be painful), and usually located around the ankles or the anterior tibial area.

You are presenting a workshop at the senior citizens center about how the changes of aging predisposes clients to vascular occlusive disorders. What would you name as the most common cause of peripheral arterial problems in the older adult? A. Aneurysm B. Coronary thrombosis C. Atherosclerosis D. Raynaud's disease

C. Atherosclerosis Rationale: Atherosclerosis is the most common cause of peripheral arterial problems in the older adult. Therefore, options A, B, and D are incorrect.

Health teaching includes advising patients on ways to reduce PAD. The nurse should always emphasize that the strongest risk factor for the development of atherosclerotic lesions is: A. Stress. B. Lack of exercise. C. Cigarette smoking. D. Obesity.

C. Cigarette smoking. Rationale: Nicotine decreases blood flow, increases heart rate and blood pressure, and increases the risk for clot formation by increasing platelet aggregation. Smokers have a four-fold higher risk of developing pain from arterial disease than nonsmokers. Carbon monoxide, produced by burning tobacco, combines with hemoglobin more readily than oxygen, thus depriving tissues of oxygen.

The nurse is caring for a client recovering from acute axillary lymphangitis. Which treatment will the nurse anticipate being prescribed for this client after antibiotic therapy has concluded? A. Arm sling B. Aspirin therapy C. Compression sleeve D. Physical therapy

C. Compression sleeve Rationale: Lymphangitis is an acute inflammation of the lymphatic channels. It arises most commonly from a focal area of infection in an extremity caused by bacteria. At the conclusion of antibiotic therapy used for an acute attack, a graduated compression sleeve should be worn on the affected extremity for several months to prevent long-term edema. An arm sling is not required. The client will not need aspirin therapy as there is no surgery and/or risk of clots. The client will not need physical therapy as there should be no lingering effects from treatment of lymphangitis.

As the clinic nurse caring for a client with varicose veins, what is an appropriate nursing action for this client? A. Assess for skin integrity. B. Assess for the sites of bleeding. C. Demonstrate how to apply and remove elastic support stockings. D. Demonstrate how to self-administer IV infusions.

C. Demonstrate how to apply and remove elastic support stockings. Rationale: The nurse demonstrates how to apply and remove elastic support stockings. Varicose veins do not require the nurse to demonstrate how to self-administer IV infusions. Varicose veins require the client to elevate legs regularly and perform leg exercises. However, it does not involve bleeding or skin lesions.

A client with venous insufficiency asks the nurse what they can do to decrease their risk of complications. What advice should the nurse provide to clients with venous insufficiency? A. Refrain from sexual activity for a week. B. Elevate the legs periodically for at least an hour. C. Elevate the legs periodically for at least 15 to 20 minutes. D. Avoid foods with iodine.

C. Elevate the legs periodically for at least 15 to 20 minutes. Rationale: The nurse should advise the client to periodically elevate the legs for at least 15 to 20 minutes. Avoiding foods with iodine or refraining from sexual activity for a week does not relate to venous insufficiency.

A client is diagnosed with peripheral arterial disease. Review of the client's chart shows an ankle-brachial index (ABI) on the right of 0.45. This indicates that the right foot has which of the following? A. No arterial insufficiency B. Very mild arterial insufficiency C. Moderate to severe arterial insufficiency D. Tissue loss to that foot

C. Moderate to severe arterial insufficiency Rationale: Normal people without arterial insufficiency have an ABI of about 1.0. Those with an ABI of 0.95 to 0.5 have mild to moderate arterial insufficiency. Those with an ABI of less than 0.50 have ischemic rest pain. Those with tissue loss have severe ischemia and an ABI of 0.25 or less.

A nurse is providing education about the prevention of arterial constriction to a client with peripheral arterial disease. Which of the following includes priority information the nurse would give to the client? A. Keep your feet elevated above your heart. B. Wear antiembolic stockings daily to assist with blood return to the heart. C. Stop smoking. D. Do not cross your legs for more than 30 minutes at a time.

C. Stop smoking. Rationale: Nicotine from tobacco products causes vasospasm and can thereby dramatically reduce circulation to the extremities. When the client elevates the feet above the heart level, the heart must work against gravity to supply blood to the feet. Antiembolic stocking are helpful for venous return to the heart, but constriction is not helpful for lack of arterial blood flow. Crossing the legs for more than a few minutes at a time compresses arteries and decreases blood supply to the legs and feet.

What should the nurse do to manage persistent swelling in a client with severe lymphangitis and lymphadenitis? A. Avoid elevating the area. B. Inform the physician if the client's temperature remains low. C. Teach the client how to apply a graduated compression stocking. D. Offer cold applications to promote comfort and to enhance circulation.

C. Teach the client how to apply a graduated compression stocking. Rationale: In severe cases of lymphangitis and lymphadenitis with persistent swelling, the nurse teaches the client how to apply a graduated compression stocking. The nurse informs the physician if the client's temperature remains elevated. The nurse recommends elevating the area to reduce the swelling and provides warmth to promote comfort and to enhance circulation.

A community health nurse teaches a group of older adults about modifiable risk factors that contribute to the development of peripheral arterial disease (PAD). The nurse knows that the teaching was effective based on which statement? A. "The older I get the higher my risk for peripheral arterial disease gets." B. "I will need to increase the amount of green leafy vegetables I eat to lower my cholesterol levels." C. "Because my family is from Italy, I have a higher risk of developing peripheral arterial disease." D. "I will need to stop smoking because the nicotine causes less blood to flow to my hands and feet."

D. "I will need to stop smoking because the nicotine causes less blood to flow to my hands and feet." Rationale: The use of tobacco products may be one of the most important risk factors in the development of atherosclerotic lesions. Nicotine in tobacco decreases blood flow to the extremities and increases heart rate and blood pressure by stimulating the sympathetic nervous system. This causes vasoconstriction, thereby decreasing arterial blood flow. It also increases the risk of clot formation by increasing the aggregation of platelets.

A nurse is providing education about maintaining tissue integrity to a client with peripheral arterial disease. Which of the following statements by the client indicates a need for clarification? A. "I can use lamb's wool between my toes if necessary." B. "I should apply powder daily because my feet perspire." C. "It is important to apply sunscreen to the top of my feet when wearing sandals." D. "Shoes made of synthetic material are best for my feet."

D. "Shoes made of synthetic material are best for my feet." Rationale: The client should wear leather shoes with an extra-depth toe box. Synthetic shoes do not allow air to circulate.

Which of the following is the hallmark symptom for peripheral arterial disease (PAD) in the lower extremity? A. Vertigo B. Dizziness C. Acute limb ischemia D. Intermittent claudication

D. Intermittent claudication Rationale: The hallmark symptom of PAD in the lower extremity is intermittent claudication. This pain may be described as aching or cramping in a muscle that occurs with the same degree of exercise or activity and is relieved with rest. Acute limb ischemia is a sudden decrease in limb perfusion, which produces new or worsening symptoms that may threaten limb viability. Dizziness and vertigo are associated with upper extremity arterial occlusive disease.

Which of the following is the most common site for a dissecting aneurysm? A. Sacral area B. Cervical area C. Lumbar area D. Thoracic area

D. Thoracic area Rationale: The thoracic area is the most common site for a dissecting aneurysm. About one-third of patients with thoracic aneurysms die of rupture of the aneurysm.

The nurse is caring for a patient with venous insufficiency. For what should the nurse assess the patient's lower extremities? A. Rubor B. Cellulitis C. Dermatitis D. Ulceration

D. Ulceration Rationale: Venous ulceration is the most serious complication of chronic venous insufficiency and can be associated with other conditions affecting the circulation of the lower extremities. Cellulitis or dermatitis may complicate the care of chronic venous insufficiency and venous ulcerations.

The term for a diagnostic test that involves injection of a contrast media into the venous system through a dorsal vein in the foot is A. lymphangiography. B. air plethysmography. C. lymphoscintigraphy. D. contrast phlebography.

D. contrast phlebography. Rationale: When a thrombus exists, an x-ray image will disclose an unfilled segment of a vein. Air plethysmography quantifies venous reflux and calf muscle pump ejection. In lymphangiography, contrast media are injected into the lymph system. In a lymphoscintigraphy, a radioactive-labeled colloid is injected into the lymph system.