PrepU ML Quiz Ch.30

A client in the emergency department states, "I have always taken a morning walk, but lately my leg cramps and hurts after just a few minutes of walking. The pain goes away after I stop walking, though." Based on this statement, which priority assessment should the nurse complete? A. Attempt to palpate the dorsalis pedis and posterior tibial pulses. B. Check for the presence of tortuous veins bilaterally on the legs. C. Assess for unilateral swelling and tenderness of either leg. D. Ask about any changes in skin color that occur in response to cold.

A

A client is hospitalized for repair of an abdominal aortic aneurysm. The nurse must be alert for signs and symptoms of aneurysm rupture and thus looks for which of the following? A. Constant, intense back pain and falling blood pressure B. Higher than normal blood pressure and falling hematocrit C.Slow heart rate and high blood pressure D. Constant, intense headache and falling blood pressure

A

A client with Raynaud's disease complains of cold and numbness in the fingers. Which of the following would the nurse identify as an early sign of vasoconstriction? A. Pallor B. Clubbing of the fingers C. Cyanosis D. Gangrene

A

A female client is readmitted to the facility with a warm, tender, reddened area on her right calf. Which contributing factor should the nurse recognize as most important? A. Recent pelvic surgery B. An active daily walking program C. History of increased aspirin use D. A history of diabetes mellitus

A

A home health nurse is teaching a client with peripheral arterial disease ways to improve circulation to the lower extremities. The nurse encourages which of the following in teaching? A. Keeping the legs in a neutral or dependent position B. Use of antiembolic stockings C. Elevation of the legs above the heart D. Application of ace wraps from the toe to below the knees

A

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. Ankle-arm indices every 12 hours C. Color of the leg every 4 hours D. Blood pressure every 2 hours

A

Providing postoperative care to a patient who has percutaneous transluminal angioplasty (PTA), with insertion of a stent, for a femoral artery lesion, includes assessment for the most serious complication of: A. Hemorrhage. B. Thrombosis of the graft. C. Decreased motor function. D. Stent dislodgement.

A

The nurse explains to a patient that the primary cause of a varicose vein is: A. An incompetent venous valve. B. Phlebothrombosis. C. Venospasm. D. Venous occlusion.

A

The nurse is caring for a client with abdominal aortic aneurysm (AAA). Which assessment finding is most likely to indicate a dissection of the aneurysm? A. Severe back pain B. Rectal bleeding C. Hypertensive crisis D. Hematemesis

A

The nurse is performing wound care for a patient with a necrotic sacral wound. The prescribed treatment is isotonic saline solution with fine mesh gauze and a dry dressing to cover. What type of debridement is the nurse performing? A. Nonselective debridement B. Surgical debridement C. Enzymatic debridement D. Selective debridement

A

Two days after undergoing a total abdominal hysterectomy, a client complains of left calf pain. Venography reveals deep vein thrombosis (DVT). When assessing this client, the nurse is likely to detect: A. left calf circumference 1" (2.5 cm) larger than the right. B. a decrease in the left pedal pulse. C. pallor and coolness of the left foot. D. loss of hair on the lower portion of the left leg.

A

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. Evident scaring C. Cyanosis D. Loose and wrinkled skin

A

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. 2.5 to 3.0 times the baseline control. C. 4.5 times the baseline control. D. 3.5 times the baseline control.

A

When assessing a client with cellulitis of the right leg, which finding should the nurse expect to observe? A. Red, swollen skin with inflammation spreading to surrounding tissues B. Small, localized blackened area of skin C. Cold, red skin D. Painful skin that is swollen and pale in color

A

When teaching a client with peripheral vascular disease about foot care, a nurse should include which instruction? A. Avoid wearing canvas shoes. B. Avoid using a nail clipper to cut toenails. C. Avoid wearing cotton socks. D. Avoid using cornstarch on the feet.

A

Which assessment finding by the nurse is the most significant finding suggestive of aortic aneurysm? A. Abdomen bruit B. Severe back pain C. Nausea and vomiting D. High blood pressure

A

Which class of medication lyses and dissolves thrombi? A. Fibrinolytic B. Factor XA inhibitors C. Platelet inhibitors D. Anticoagulant

A

Which of the following are alterations noted in Virchow's triad? Select all that apply. A. Altered coagulation B. Stasis of blood C. Tenderness D. Vessel wall injury E. Edema

A, B, D

A patient is suspected to have a thoracic aortic aneurysm. What diagnostic test(s) does the nurse anticipate preparing the patient for? (Select all that apply.) A. Transesophageal echocardiography B. Computed tomography C. Electrocardiogram (ECG) D. Electroencephalogram E. X-ray

A, D

A client has been diagnosed with Raynaud's disease. Which self-care strategies minimize risks associated with this disease? Select all that apply. A. Wear gloves to protect hands from injury when performing tasks. B. Avoid over-the-counter decongestants and cold remedies. C. Limit activities that place stress on the ulnar nerve. D. Refrain from going outdoors in cold weather. E. Do not smoke, or stop smoking.

A,B, E

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. Moderate to severe arterial insufficiency C. Very mild arterial insufficiency D. Tissue loss to that foot

B

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. Peripheral vascular disease B. Raynaud's disease C. Arterial occlusive diseases D. Buerger's disease

B

A home health nurse is seeing an elderly male client for the first time. During the physical assessment of the skin on the lower legs, the nurse notes edema, brown pigmentation in the gaiter area, pedal pulses, and a few irregularly shaped ulcers around the ankles. From these findings, the nurse knows that the client has a problem with peripheral circulation. Which of the following does the nurse suspect? A. Trauma B. Venous insufficiency C. Neither venous nor arterial insufficiency D. Arterial insufficiency

B

A nurse and physician are preparing to visit a hospitalized client with peripheral arterial disease. As you approach the client's room, the physician asks if the client has reported any intermittent claudication. The client has reported this symptom. The nurse explains to the physician which of the following details? A. The client experiences shortness of breath after walking about 50 feet. B. The client can walk about 50 feet before getting pain in the right lower leg. C. The client's fingers tingle when left in one position for too long. D. The client's legs awaken him during the night with itching.

B

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

A patient with diabetes is being treated for a wound on the lower extremity that has been present for 30 days. What option for treatment is available to increase diffusion of oxygen to the hypoxic wound? A. Surgical debridement B. Hyperbaric oxygen C. Vacuum-assisted closure device D. Enzymatic debridement

B

The most common site of aneurysm formation is in the: A. aortic arch, around the ascending and descending aorta. B. abdominal aorta, just below the renal arteries. C. ascending aorta, around the aortic arch. D. descending aorta, beyond the subclavian arteries.

B

The most important reason for a nurse to encourage a client with peripheral vascular disease to initiate a walking program is that this form of exercise: A. aids in weight reduction. B. decreases venous congestion. C. increases high-density lipoprotein (HDL) level. D. reduces stress.

B

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. Aching, cramping pain B. Diminished or absent pulses C.Superficial ulcer D. Pulses that are present but difficult to palpate

B

The nurse is caring for a patient who has started anticoagulant therapy with warfarin (Coumadin). When does the nurse understand that therapeutic benefits will begin? A. In 2 days B. In 3 to 5 days C. Within 12 hours D. Within the first 24 hours

B

The nurse is caring for a patient with peripheral arterial insufficiency. What can the nurse suggest to help relieve leg pain during rest? A. Elevating the limb above heart level B. Lowering the limb so that it is dependent C. Placing the limb in a plane horizontal to the body D. Massaging the limb after application of cold compresses

B

The nurse is performing wound care for a patient with a necrotic sacral wound. The prescribed treatment is isotonic saline solution with fine mesh gauze and a dry dressing to cover. What type of debridement is the nurse performing? A. Surgical debridement B. Nonselective debridement C. Selective debridement D. Enzymatic debridement

B

Which of the following is the most effective intervention for preventing progression of vascular disease? A. Avoid trauma B. Risk factor modification C. Wear sturdy shoes D. Use neutral soaps

B

A client admitted to the medical-surgical unit with a venous thromboembolism (VTE) is started on enoxaparin and warfarin. The client asks the nurse why two medications are needed. Which response by the nurse is accurate? A. "Because of the potential for a pulmonary embolism, it is important for you to take at least two anticoagulants." B. "Enoxaparin will dissolve the clot, and warfarin will prevent any more clots from occurring." C. "The enoxaparin will work immediately, but the warfarin takes several days to achieve its full effect." D. "Administration of two anticoagulants decreases the risk of recurrent venous thrombosis."

C

A client with a diagnosed abdominal aortic aneurysm (AAA) develops severe lower back pain. Which is the most likely cause? A. The aneurysm has become obstructed. B. The client is experiencing inflammation of the aneurysm. C. The aneurysm may be preparing to rupture. D. The client is experiencing normal sensations associated with this condition.

C

A client with no known history of peripheral vascular disease comes to the emergency department complaining of sudden onset of lower leg pain. Inspection and palpation reveal absent pulses; paresthesia; and a mottled, cyanotic, cold, and cadaverous left calf. While the physician determines the appropriate therapy, the nurse should: A. elevate the affected leg as high as possible. B. shave the affected leg in anticipation of surgery. C. keep the affected leg level or slightly dependent. D. place a heating pad around the affected calf.

C

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. "Because my family is from Italy, I have a higher risk of developing peripheral arterial disease." B. "The older I get the higher my risk for peripheral arterial disease gets." C. "I will need to stop smoking because the nicotine causes less blood to flow to my hands and feet." D. "I will need to increase the amount of green leafy vegetables I eat to lower my cholesterol levels."

C

A health care provider wants a cross-sectional image of the abdomen to evaluate the degree of stenosis in a patient's left common iliac artery. The nurse knows to prepare the patient for which of the following? A. Magnetic resonance angiography (MRA) B. Doppler ultrasound C. Computed tomography angiography (CTA) D. Angiography

C

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. Extend the leg, plantar flex the foot, and check for the patency of the dorsalis pedis pulse. B. Lower the patient's legs and massage the calf muscles to note any areas of tenderness. C. Dorsiflex the foot while the leg is elevated to check for calf pain. D. Elevate the patient's legs for 20 minutes and then lower them slowly while checking for areas of inadequate blood return.

C

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. Increasing blood pressure and monitoring fluid intake and output B. Increasing blood pressure and reducing mobility C. Stabilizing heart rate and blood pressure and easing anxiety D. Decreasing blood pressure and increasing mobility

C

Providing postoperative care to a patient who has percutaneous transluminal angioplasty (PTA), with insertion of a stent, for a femoral artery lesion, includes assessment for the most serious complication of: A. Decreased motor function. B. Thrombosis of the graft. C. Hemorrhage. D. Stent dislodgement.

C

The nurse is caring for a client with Raynaud's disease. What are important instructions for a client who is diagnosed with this disease to prevent an attack? A. Take over-the-counter decongestants. B. Report changes in the usual pattern of chest pain. C. Avoid situations that contribute to ischemic episodes. D. Avoid fatty foods and exercise.

C

Which nursing diagnosis is most significant in planning the care for a client with Raynaud's disease? A. Self-Care Deficit B. Activity Intolerance C. Acute Pain D. Disturbed Sensory Perception

C

Which of the following assessment results is considered a major risk factor for PAD? A. LDL of 100 mg/dL B. Cholesterol of 200 mg/dL C. BP of 160/110 mm Hg D. Triglyceride level of 150 mg/dL

C

Which of the following is a characteristic of an arterial ulcer? A. Edema may be severe B. Brawny edema C. Border regular and well demarcated D. Ankle-brachial index (ABI) > 0.90

C

Which risk factor is related to venous stasis for deep vein thrombosis (DVT) and pulmonary embolism (PE)? A. Pacing wires B. Surgery C. Obesity D. Trauma

C

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

C

With a severe degree of peripheral arterial insufficiency, leg pain during rest can be reduced by: A. Elevating the limb over the heart level. B. Placing the limb in a plane horizontal to the body. C. Lowering the limb so that it is dependent. D. Massaging the limb after application of cold compresses.

C

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

A client has been diagnosed with peripheral arterial occlusive disease. Which of the following instructions is appropriate for the nurse to give the client for promoting circulation to the extremities? A. Use a heating pad to promote warmth. B. Keep the extremities elevated slightly. C. Massage the calf muscles if pain occurs. D. Participate in a regular walking program.

D

A client is receiving enoxaparin and warfarin therapy for a venous thromboembolism (VTE). Which laboratory value indicates that anticoagulation is adequate and enoxaparin can be discontinued? A. Prothrombin time (PT) is 0.5 times normal. B. K+ level is 3.5. C. Activated partial thromboplastin time (aPPT) is half of the control value D. International normalized ratio (INR) is 2.5.

D

A client is recovering from surgical repair of a dissecting aortic aneurysm. Which assessment findings indicate possible bleeding or recurring dissection? A. Urine output of 150 ml/hour and heart rate of 45 beats/minute B. Blood pressure of 82/40 mm Hg and heart rate of 45 beats/minute C. Urine output of 15 ml/hour and 2+ hematuria D. Blood pressure of 82/40 mm Hg and heart rate of 125 beats/minute

D

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. Avoid foods with iodine. C. Elevate the legs periodically for at least an hour. D. Elevate the legs periodically for at least 15 to 20 minutes.

D

A nurse is admitting a new client with a deep vein thrombosis in her left leg. During the admission process, which information provided by the client would be a contraindication to anticoagulant therapy? A. Diet that includes many green, leafy vegetables every day B. Three vaginal births, the most recent 18 months ago C. A cerebral vascular bleed 10 years ago D. Scheduled eye surgery in 1 week

D

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. Do not cross your legs for more than 30 minutes at a time. C. Wear antiembolic stockings daily to assist with blood return to the heart. D. Stop smoking.

D

A nursing instructor is discussing the diagnosis of intermittent claudication with students. To determine whether the students understand the pathophysiology of the disease, the instructor asks, "What percentage of the arterial lumen must be obstructed before intermittent claudication is experienced?" What answer should the students give? A. 20 B. 30 C. 40 D. 50

D

A patient is admitted to a special critical care unit for the treatment of an arterial thrombus. The nurse is aware that the preferred drug of choice for clot removal, unless contraindicated, would be: A. Streptokinase B. Reteplase. C. Urokinase. D. Alteplase.

D

Aortic dissection may be mistaken for which of the following disease processes? A. Pneumothorax B. Stroke C. Angina D. Myocardial infarction (MI)

D

In a client with a bypass graft, the distal outflow vessel must have at least what percentage patency for the graft to remain patent? A. 20 B. 30 C. 40 D. 50

D

The most important factor regulating the caliber of blood vessels, which determines resistance to flow, is: A. The influence of circulating chemicals. B. Independent arterial wall activity. C. Hormonal secretion. D. The sympathetic nervous system.

D

The nurse is assessing a hospital client who has low albumin levels due to liver disease. What assessment finding should the nurse attribute to the client's low albumin levels? A. The client has had two episodes of epistaxis (nosebleeds) in the past 24 hours. B. The client reports uncharacteristic levels of fatigue. C. The client is short of breath on exertion, with an expiratory wheeze. D. There is severe edema to the client's legs and abdomen.

D

The nurse is assisting a patient with peripheral arterial disease to ambulate in the hallway. What should the nurse include in the education of the patient during ambulation? A. "If you feel any discomfort, stop and we will use a wheelchair to take you back to your room." B. "As soon as you feel pain, we will go back and elevate your legs." C. "If you feel pain during the walk, keep walking until the end of the hallway is reached." D. "Walk to the point of pain, rest until the pain subsides, then resume ambulation."

D

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

D

The nurse is monitoring a patient who is on heparin anticoagulant therapy. What should the nurse determine the therapeutic range of the international normalized ratio (INR) should be? A. 7.0-8.0 B. 5.0-6.0 C. 4.0-5.0 D. 2.0-3.0

D

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. lymphoscintigraphy. B. lymphangiography. C. air plethysmography. D. contrast phlebography.

D

To assess the dorsalis pedis artery, the nurse would use the tips of three fingers and apply light pressure to the: A. Inside of the ankle just above the heel. B. Outside of the foot just below the heel. C. Exterior surface of the foot near the heel. D. Anterior surface of the foot near the ankle joint.

D

To check for arterial insufficiency when a client is in a supine position, the nurse should elevate the extremity at a 45-degree angle and then have the client sit up. The nurse suspects arterial insufficiency if the assessment reveals: A. a 30-second filling time for the veins. B. elevational rubor. C. no rubor for 10 seconds after the maneuver. D. elevational pallor.

D

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

D

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

D

Which aneurysm results in bleeding into the layers of the arterial wall? A. False B. Saccular C. Anastomotic D. Dissecting

D

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

D

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

D

Which of the following medications is considered a thrombolytic? A. Heparin B. Coumadin C. Lovenox D. Alteplase

D