Ch 30 Ass & Mgmt of Pt Peripheral Circ prob
A nurse is reviewing self-care measures for a client with peripheral vascular disease. Which statement indicates proper self-care measures?
"I have my wife look at the soles of my feet each day."
The nurse completes discharge teaching for a patient following a femoral-to-popliteal bypass graft. What response by the patient would indicate teaching was effective?
"I will call if I develop any coldness, numbness, tingling, or pain in the surgical leg."
The nurse is caring for a patient with venous insufficiency. What should the nurse assess the patient's lower extremities for?
Ulceration
What are the symptoms a nurse should assess for in a patient with lymphedema as a result of impaired nutrition to the tissue?
Ulcers and infection in the edematous area
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?
Hyperbaric oxygen
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?
In 3 to 5 days
Which sign or symptom suggests that a client's abdominal aortic aneurysm is extending?
Increased abdominal and back pain
A client is diagnosed with deep vein thrombosis (DVT). Which nursing diagnosis should receive highest priority at this time?
Ineffective peripheral tissue perfusion related to venous congestion
The nurse is caring for a patient with peripheral arterial insufficiency. What can the nurse suggest to help relieve leg pain during rest?
Lowering the limb so that it is dependent
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?
Moderate to severe arterial insufficiency
Aortic dissection may be mistaken for which of the following disease processes?
Myocardial infarction (MI)
Which of the following are risk factors for venous disorders of the lower extremities?
Obesity
The nurse teaches the patient with peripheral vascular disease (PVD) to refrain from smoking because nicotine causes which of the following?
Vasospasm
A nurse is caring for a client following an arterial vascular bypass graft in the leg. Over the next 24 hours, what should the nurse plan to assess?
Peripheral pulses every 15 minutes following surgery
A postoperative client is receiving heparin after developing thrombophlebitis. The nurse monitors the client carefully for bleeding and other adverse effects of heparin. If the client starts to exhibit signs of excessive bleeding, the nurse should expect to administer an antidote that is specific to heparin. Which agent fits this description?
Protamine sulfate
A physician orders blood coagulation tests to evaluate a client's blood-clotting ability. The nurse knows that such tests are important in assessing clients at risk for thrombi, such as those with a history of atrial fibrillation, infective endocarditis, prosthetic heart valves, or myocardial infarction. Which test determines a client's response to oral anticoagulant drugs?
Prothrombin time (PT)
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?
Atherosclerosis
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?
Avoid situations that contribute to ischemic episodes.
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 gater 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?
Venous insufficiency
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 contrast phlebography.
A community health nurse teaches a group of seniors 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 of the following statements?
"I will need to stop smoking because the nicotine causes less blood to flow to my hands and feet."
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?
"Shoes made of synthetic material are best for my feet."
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?
"Walk to the point of pain, rest until the pain subsides, then resume ambulation."
When administering heparin anticoagulant therapy, the nurse needs to make certain that the activated partial thromboplastin time (aPTT) is within the therapeutic range of:
1.5 to 2.5 times the baseline control.
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?
Arterial insufficiency
To assess the dorsalis pedis artery, the nurse would use the tips of three fingers and apply light pressure to the:
Anterior surface of the foot near the ankle joint.
A pregnant client who developed deep vein thrombosis (DVT) in her right leg is receiving heparin I.V. on the medical floor. Physical therapy is ordered to maintain her mobility and prevent additional DVT. A nursing assistant working on the medical unit helps the client with bathing, range-of-motion exercises, and personal care. Which collaborative multidisciplinary considerations should the care plan address?
The client is at risk for heparin-induced thrombocytopenia; therefore, the care plan should include reporting evidence of bleeding or easy bruising.
A client is recovering from surgical repair of a dissecting aortic aneurysm. Which assessment findings indicate possible bleeding or recurring dissection?
Blood pressure of 82/40 mm Hg and heart rate of 125 beats/minute
Pentoxifylline (Trental) is a medication used for which of the following conditions?
Claudication
Health teaching for a patient diagnosed with Raynaud's phenomenon would include advising the patient to avoid the most common factor known to trigger episodes. Which of the following is the most common factor?
Cold and stress
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.)
Computed tomography Transesophageal echocardiography X-ray
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?
Constant, intense back pain and falling blood pressure
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 which of the following?
Contrast phlebography
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?
Contrast phlebography
Which of the following are complications of percutaneous transluminal balloon angioplasty (PTA)? Select all that apply.
Hematoma Embolization Dissection of the vessel Bleeding Stent migration
As the clinic nurse caring for a client with varicose veins, what is an appropriate nursing action for this client?
Demonstrate how to apply and remove elastic support stockings.
The nurse performing an assessment on a patient who has arterial insufficiency of the legs and an ulcer on the left great toe would expect to find which of the following characteristics?
Diminished or absent pulses
Which of the following are characteristics of arterial insufficiency?
Diminished or absent pulses
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?
Dorsiflex the foot while the leg is elevated to check for calf pain.
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?
Elevate the legs periodically for at least 15 to 20 minutes.
A patient is having an angiography to detect the presence of an aneurysm. After the contrast is administered by the interventionist, the patient begins to complain of nausea and difficulty breathing. What medication is a priority to administer at this time?
Epinephrine
Which of the following is accurate regarding Raynaud's disease?
Episodes may be triggered by unusual sensitivity to cold.
Which of the following statements is accurate regarding Reynaud's disease?
Episodes may be triggered by unusual sensitivity to cold.
The most important factor regulating the caliber of blood vessels, which determines resistance to flow, is:
The sympathetic nervous system.
Which of the following is the most common site for a dissecting aneurysm?
Thoracic area
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?
Raynaud's disease
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?
Recent pelvic surgery
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?
Stabilizing heart rate and blood pressure and easing anxiety
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?
Stop smoking.
On a routine visit to the physician, a client with chronic arterial occlusive disease reports that he's stopped smoking after 34 years. To relieve symptoms of intermittent claudication, a condition associated with chronic arterial occlusive disease, which additional measure should the nurse recommend?
Taking daily walks
What should the nurse do to manage the persistent swelling in a patient with severe lymphangitis and lymphadenitis?
Teach the patient how to apply a graduated compression stocking.
A patient with a diagnosed abdominal aortic aneurysm (AAA) develops severe lower back pain. Which of the following is the most likely cause?
The aneurysm may be preparing to rupture.
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:
decreases venous congestion
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:
dependent pallor.
