Chap 30-Assessment and Management of Pts with Vascular Disorders

To assess the dorsalis pedis artery, the nurse would use the tips of three fingers and apply light pressure to the: a) Anterior surface of the foot near the ankle joint. b) Exterior surface of the foot near the heel. c) Outside of the foot just below the heel. d) Inside of the ankle just above the heel.

a) Anterior surface of the foot near the ankle joint.

Pentoxifylline (Trental) is a medication used for which of the following conditions? a) Claudication b) Elevated triglycerides c) Hypertension d) Thromboemboli

a) Claudication

A client who underwent total hip replacement exhibits a red, painful area on the calf of the affected leg. What test validates presence of thromboembolism? a) Homans' b) Phalen's c) Rinne d) Romberg's

a) Homans'

Which of the following is the hallmark symptom for peripheral arterial disease (PAD) in the lower extremity? a) Intermittent claudication b) Acute limb ischemia c) Dizziness d) Vertigo

a) Intermittent claudication

Aortic dissection may be mistaken for which of the following disease processes? a) Myocardial infarction (MI) b) Angina c) Stroke d) Pneumothorax

a) Myocardial infarction (MI)

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, cool skin temperature, and pallor b) Numbness, warm skin temperature, and redness c) Redness, cool skin temperature, and swelling d) Swelling, warm skin temperature, and drainage

a) Numbness, cool skin temperature, and pallor

Which is a risk factor for venous disorders of the lower extremities? a) Obesity b) Surgery c) Pacing wires d) Trauma

a) Obesity

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? a) Prothrombin time (PT) b) Platelet count c) Partial thromboplastin time (PTT) d) Bleeding time

a) Prothrombin time (PT)

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) Stop smoking. b) Wear antiembolytic stockings daily to assist with blood return to the heart. c) Do not cross your legs for more than 30 minutes at a time. d) Keep your feet elevated above your heart.

a) Stop smoking

The nurse is caring for a patient with venous insufficiency. What should the nurse assess the patient's lower extremities for? a) Ulceration b) Rudor c) Dermatitis d) Cellulitis

a) Ulceration

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? a) Venous insufficiency b) Neither venous nor arterial insufficiency c) Trauma d) Arterial insufficiency

a) Venous insufficiency

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 aneurysm may be preparing to rupture. c) The client is experiencing normal sensations associated with this condition. d) The client is experiencing inflammation of the aneurysm.

b) The aneurysm may be preparing to rupture

Which of the following is the most common site for a dissecting aneurysm? a) Sacral area b) Thoracic area c) Cervical area d) Lumbar area

b) Thoracic area

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) "Administration of two anticoagulants decreases the risk of recurrent venous thrombosis." b) "The enoxaparin will work immediately, but the warfarin takes several days to achieve its full effect." c) "Enoxaparin will dissolve the clot, and warfarin will prevent any more clots from occurring." d) "Because of the potential for a pulmonary embolism, it is important for you to take at least two anticoagulants."

b) "The enoxaparin will work immediately, but the warfarin takes several days to achieve its full effect."

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) Slow heart rate and high blood pressure b) Constant, intense back pain and falling blood pressure c) Higher than normal blood pressure and falling hematocrit d) Constant, intense headache and falling blood pressure

b) 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? a) Lymphoscintigraphy b) Contrast phlebography c) Lymphangiography d) Air plethysmography

b) Contrast phlebography

Which is a characteristic of arterial insufficiency? a) Pulses are present but may be difficult to palpate b) Diminished or absent pulses c) Aching, cramping pain d) Superficial ulcer

b) Diminished or absent pulses

Which of the following aneurysms results in bleeding into the layers of the arterial wall? a) Anastomotic b) Dissecting c) False d) Saccular

b) Dissecting

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

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) Within the first 24 hours b) In 3 to 5 days c) In 2 days d) Within 12 hours

b) In 3 to 5 days

Which of the following is the most effective intervention for preventing progression of vascular disease? a) Use neutral soaps b) Risk factor modification c) Avoid trauma d) Wear sturdy shoes

b) Risk factor modification

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 reducing mobility d) Increasing blood pressure and monitoring fluid intake and output

b) Stabilizing heart rate and blood pressure and easing anxiety

The nurse is caring for a client who is status post operative from a vein stripping. What would the nurse monitor for? a) Blood on the dressing on the inoperative leg b) Swelling in the operative leg c) Swelling in the inoperative leg d) Warm, pink toes in the inoperative leg

b) Swelling in the operative leg

What should the nurse do to manage the persistent swelling in a patient with severe lymphangitis and lymphadenitis? a) Inform the physician if the temperature remains low. b) Teach the patient how to apply a graduated compression stocking. c) Avoid elevating the area. d) Offer cold applications to promote comfort and to enhance circulation.

b) Teach the patient how to apply a graduated compression stocking.

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

b) forcing blood into the deep venous system.

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? a) "I will need to increase the amount of green leafy vegetables I eat to lower my cholesterol levels." b) "Since my family is from Italy, I have a higher risk of developing peripheral arterial disease." c) "I will need to stop smoking because the nicotine causes less blood to flow to my hands and feet." d) "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."

A 56-year-old woman with severe varicose veins has opted for venous ablation, and the nurse is providing patient education before the scheduled procedure. What instructions should the nurse provide to this patient? a) "If you notice any bruising in the area, make sure to let someone know because that could be a sign of a serious complication." b) "You might experience some pain after the procedure, but this will be managed with ice packs rather than medications." c) "We'll help you get walking as soon as you sedation has worn off, and you'll continue to gradually increase your activity level." d) "Try to limit your activity for the first 10 days to 2 weeks to prevent reoccurrence of your varicose veins."

c) "We'll help you get walking as soon as you sedation has worn off, and you'll continue to gradually increase your activity level."

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) 4.0-5.0 b) 5.0-6.0 c) 2.0-3.0 d) 7.0-8.0

c) 2.0-3.0

A patient with a diagnosis of deep vein thrombosis (DVT) is being treated with unfractionated heparin, which is being administered intravenously. The nurse who is providing care for this patient should consequently prioritize what assessments? a) Monitoring the patient's intake and output, and assessing for signs of fluid volume deficit b) Assessing the patient's pain levels c) Assessing the patient for internal or external hemorrhage d) Assessing the patient for adventitious lung sounds and assessing SaO2 levels

c) Assessing the patient for internal or external hemorrhage

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

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) Obesity. b) Lack of exercise. c) Cigarette smoking. d) Stress.

c) Cigarette smoking.

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) Lymphangiography c) Contrast phlebography d) Air plethysmography

c) Contrast phlebography

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? a) Superficial ulcer b) Aching, cramping pain c) Diminished or absent pulses d) Pulses are present, may be difficult to palpate

c) Diminished or absent pulses

Which of the following is accurate regarding Raynaud's disease? a) It affects more than two digits on each hand or foot. b) It is generally bilateral. c) Episodes may be triggered by unusual sensitivity to cold. d) It is most common in men aged 16 to 40 years.

c) Episodes may be triggered by unusual sensitivity to cold.

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

A patient with impaired renal function is scheduled for a multidetector computer tomography (MDCT) scan. What preprocedure medication may the nurse administer to this patient? a) Dipyridamole (Persantine) b) Epinephrine c) Oral N-acetylcysteine d) Oral iodine

c) Oral N-acetylcysteine

The nurse teaches the patient with peripheral vascular disease (PVD) to refrain from smoking because nicotine causes a) depression of the cough reflex. b) diuresis. c) a vasospasm. d) a slowed heart rate.

c) a vasospasm.

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) reduces stress. b) aids in weight reduction. c) decreases venous congestion. d) increases high-density lipoprotein (HDL) level.

c) decreases venous congestion.

When caring for a patient with leg ulcers, the positioning of the legs depends on whether the patient's ulcer is arterial or venous in origin. How should the nurse best position a patient who has leg ulcers that are venous in origin? a)Keep the patient's legs flat and straight. b)Keep the patient's knees bent to 45-degree angle and supported with pillows. c)Elevate the patient's lower extremities. d)Dangle the patient's legs over the side of the bed.

c)Elevate the patient's lower extremities.

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) 50

The nurse is working with a client who has just been diagnosed with an aneurysm. What advice should the nurse provide to this client? a) Avoid situations that contribute to ischemic episodes. b) Wear wool socks and mittens during cold weather. c) Minimize bowel movements and coughing. d) Avoid straining during bowel movements and coughing.

d) Avoid straining during bowel movements and coughing.

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) Urine output of 15 ml/hour and 2+ hematuria c) Blood pressure of 82/40 mm Hg and heart rate of 45 beats/minute d) Blood pressure of 82/40 mm Hg and heart rate of 125 beats/minute

d) Blood pressure of 82/40 mm Hg and heart rate of 125 beats/minute

The nurse assesses a patient with hip pain related to intermittent claudication. She knows that the area of arterial narrowing is the: a) Anterior tibial. b) Common femoral artery. c) Posterior tibial. d) Common iliac artery.

d) Common iliac artery

A woman has sought care from her nurse practitioner for the treatment of a wound on her lower leg that has been slow to heal. When planning this patient's care, what action should the nurse first perform? a) Take a culture and sensitivity swab from the wound bed. b) Prescribe the woman a course of broad-spectrum antibiotics. c) Cleanse the wound bed with normal saline and apply a hydrocolloid dressing. d) Determine whether the ulcer results from arterial insufficiency or venous insufficiency.

d) Determine whether the ulcer results from arterial insufficiency or venous insufficiency.

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) Decreased pulse rate and blood pressure d) Increased abdominal and back pain

d) Increased abdominal and back pain

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) Activated partial thromboplastin time (aPPT) is half of the control value b) Prothrombin time (PT) is 0.5 times normal. c) K+ level is 3.5. d) International normalized ratio (INR) is 2.5.

d) International normalized ratio (INR) is 2.5.

The nurse is caring for a patient who returned from the tropics 2 weeks ago. The patient has been diagnosed with lymphangitis and is experiencing lymphedema. You are aware that the lymphedema may be due to what? a) Improper anticoagulant use b) Excessive lymph is the vascular space c) Sensitivity to antibiotics d) Obstructed lymph vessels

d) Obstructed lymph vessels

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? a) Thrombin b) Plasma protein fraction c) Phytonadione (vitamin K) d) Protamine sulfate

d) Protamine sulfate