Chapt 30 Cardiovascular Med Surg
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
Moderate to severe arterial insufficiency 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.
Aortic dissection may be mistaken for which of the following disease processes? a) Myocardial infarction (MI) b) Angina c) Stroke d) Pneumothorax
Myocardial infarction (MI) Aortic dissection may be mistaken for an acute MI, which could confuse the clinical picture and initial treatment. Aortic dissection is not mistaken for stroke, pneumothorax, or angina.
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) Swelling, warm skin temperature, and drainage b) Numbness, warm skin temperature, and redness c) Numbness, cool skin temperature, and pallor d) Redness, cool skin temperature, and swelling
Numbness, cool skin temperature, and pallor 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.
Which of the following are risk factors for venous disorders of the lower extremities? a) Trauma b) Pacing wires c) Obesity d) Surgery
Obesity Careful assessment is invaluable in detecting early signs of venous disorders of the lower extremities. Patients with a history of varicose veins, hypercoagulation, neoplastic disease, cardiovascular disease, or recent major surgery or injury are at high risk. Other patients at high risk include those who are obese or older adults and women taking oral contraceptives.
Which of the following are risk factors related to venous stasis for DVT and pulmonary embolism? a) Trauma b) Surgery c) Obesity d) Pacing wires
Obesity Obesity is a risk factor for DVT and PE related to venous stasis. Trauma, pacing wires, and surgery are related to endothelial damage as a risk factor for DCAT and PE.
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) loss of hair on the lower portion of the left leg. b) left calf circumference 1" (2.5 cm) larger than the right. c) pallor and coolness of the left foot. d) a decrease in the left pedal pulse.
left calf circumference 1" (2.5 cm) larger than the right. Signs of DVT include inflammation and edema in the affected extremity, causing its circumference to exceed that of the opposite extremity. Pallor, coolness, decreased pulse, and hair loss in an extremity signal interrupted arterial blood flow, which doesn't occur in DVT.
A nurse is reviewing self-care measures for a client with peripheral vascular disease. Which statement indicates proper self-care measures? a) "I stopped smoking and use only chewing tobacco." b) "I like to soak my feet in the hot tub every day." c) "I walk only to the mailbox in my bare feet." d) "I have my wife look at the soles of my feet each day."
"I have my wife look at the soles of my feet each day." A client with peripheral vascular disease should examine his feet daily for redness, dryness, or cuts. If a client isn't able to do this examination on his own, then a caregiver or family member should help him. A client with peripheral vascular disease should avoid hot tubs because decreased sensation in the feet may make him unable to tell if the water is too hot. The client should always wear shoes or slippers on his feet when he is out of bed to help minimize trauma to the feet. Any type of nicotine, whether it's from cigarettes or smokeless tobacco, can cause vasoconstriction and further decrease blood supply to the extremities.
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? a) "It will important for me to sit at the kitchen table to promote better breathing." b) "I can now stop taking my Lipitor because my leg is fixed." c) "I can stop the exercises that were started in the hospital once I return home." d) "I will call if I develop any coldness, numbness, tingling, or pain in the surgical leg."
"I will call if I develop any coldness, numbness, tingling, or pain in the surgical leg." The nurse ensures that the patient has the knowledge and ability to assess for any postoperative complications such as infection, occlusion of the artery or graft, and decreased blood flow. Coldness, numbness, tingling, and pain are signs of peripheral arterial occlusion, and immediate intervention is required.
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."
"I will need to stop smoking because the nicotine causes less blood to flow to my hands and feet." 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 client with peripheral arterial disease asks the nurse about using a heating pad to warm the feet. The nurse's best response is which of the following? a) "It is better to soak your feet in hot water as long as the water temperature is below 110 degrees F." b) "A heating pad to your feet is a good idea because it increases the metabolic rate." c) "It is better to put the heating pad on your abdomen, which causes vasodilation and warmth to your feet." d) "A heating pad to your feet is fine as long as the temperature stays below 105 degrees F."
"It is better to put the heating pad on your abdomen, which causes vasodilation and warmth to your feet." It is safer to apply a heating pad to the abdomen, causing a reflex vasodilation in the extremities. Heat may be applied directly to ischemic extremities; however, the temperature of the heating source must not exceed body temperature. Excess heat may increase the metabolic rate of the extremities and increase the need for oxygen beyond that provided by the reduced arterial flow through the diseased artery.
A client complains of leg pain brought on by walking several blocks — a symptom that first arose several weeks earlier. The client's history includes diabetes mellitus and a two-pack-per-day cigarette habit for the past 42 years. The physician diagnoses intermittent claudication and orders pentoxifylline (Trental), 400 mg three times daily with meals. Which instruction concerning long-term care should the nurse provide? a) "See the physician if complications occur." b) "Reduce your level of exercise." c) "Practice meticulous foot care." d) "Consider cutting down on your smoking."
"Practice meticulous foot care." Intermittent claudication and other chronic peripheral vascular diseases reduce oxygenation to the feet, making them susceptible to injury and poor healing. Therefore, meticulous foot care is essential. The nurse should teach the client to bathe his feet in warm water and dry them thoroughly, cut the toenails straight across, wear well-fitting shoes, and avoid taking medications without the approval of a physician. Because nicotine is a vasoconstrictor, this client should stop smoking, not just consider cutting down. Daily walking is beneficial to clients with intermittent claudication. To evaluate the effectiveness of the therapeutic regimen, this client should see the physician regularly, not just when complications occur.
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) "Shoes made of synthetic material are best for my feet." b) "I should apply powder daily because my feet perspire." c) "I can use lamb's wool between my toes if necessary." d) "It is important to apply sunscreen to the top of my feet when wearing sandals."
"Shoes made of synthetic material are best for my feet." The client should wear leather shoes with an extra-depth toebox. Synthetic shoes do not allow air to circulate.
A patient admitted to the medical surgical unit with a venous thromboembolism (VTE) is started on enoxaparin (Lovenox) and warfarin (Coumadin). The patient asks the nurse why two medications are needed. Which response by the nurse is accurate? a) "Lovenox will dissolve the clot, and Coumadin will prevent any more clots from occurring." b) "Administration of two anticoagulants decreases the risk of recurrent venous thrombosis." c) "The Lovenox will work immediately, but the Coumadin takes several days to reach its full effect." d) "Because of the potential for a pulmonary embolism, it is important for you to have at least two anticoagulants."
"The Lovenox will work immediately, but the Coumadin takes several days to reach its full effect." Oral anticoagulants, such as warfarin, are monitored by the prothrombin time (PT) or the international normalized ratio (INR). Because the full anticoagulant effect of warfarin is delayed for 3 to 5 days, it is usually administered concurrently with heparin until desired anticoagulation has been achieved (ie, when the PT is 1.5 to 2 times normal or the INR is 2.0 to 3.0).
In a patient with a bypass graft, the distal outflow vessel must be at least what percentage patent for the graft to remain patent? a) 40 b) 20 c) 50 d) 30
50 The distal outflow vessel must be at least 50% patent for the graft to remain patent.
Which of the following diagnostic tests are used to quantify venous reflux and calf muscle pump ejection? a) Lymphangiography b) Air plethysmography c) Lymphoscintigraphy d) Contrast phlebography
Air plethysmography Air plethysmography is used to quantify venous reflux and calf muscle pump action. Contrast phlebography involves injecting a radiopaque contrast agent into the venous system. Lymphoscintigraphy is done when a radioactively labeled colloid is injected subcutaneously in the second interdigital space. The extremity is then exercised to facilitate the uptake of the colloid by the lymphatic system, and serial images are obtained at present intervals. Lymphoangiography provides a way of detecting lymph node involvement resulting from metastatic carcinoma, lymphoma, or infection in sites that are otherwise inaccessible to the examiner except by surgery.
Which aneurysm occurs as a result of infection at arterial suture or graft sites? a) Dissecting b) Anastomotic c) False d) Saccular
Anastomotic An anastomotic aneurysm occurs as a result of infection at arterial suture or graft sites. Dissection results from a rupture in the intimal layer, resulting in bleeding between the intimal and medial layers of the arterial wall. Saccular aneurysms collect blood in the weakened outpouching. In a false aneurysm, the mass is actually a pulsating hematoma
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
Arterial insufficiency Characteristics of arterial insuffiency 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 anterier 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
Atherosclerosis Atherosclerosis is the most common cause of peripheral arterial problems in the older adult. Therefore, options A, B, and D are incorrect.
A patient 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) Ask about any skin color changes that occur in response to cold. b) Assess for unilateral swelling and tenderness of either leg. c) Attempt to palpate the dorsalis pedis and posterior tibial pulses. d) Check for the presence of tortuous veins bilaterally on the legs.
Attempt to palpate the dorsalis pedis and posterior tibial pulses. Intermittent claudication is a sign of peripheral arterial insufficiency. The nurse should assess for other clinical manifestations of peripheral arterial disease in a patient who describes intermittent claudication. A thorough assessment of the patient's skin color and temperature and the character of the peripheral pulses are important in the diagnosis of arterial disorders.
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) Avoid situations that contribute to ischemic episodes. b) Avoid fatty foods and exercise. c) Take over-the-counter decongestants. d) Report changes in the usual pattern of chest pain.
Avoid situations that contribute to ischemic episodes. Teaching for clients with Raynaud's disease and their family members is important. The nurse should instruct the clients to avoid situations that contribute to ischemic episodes. Reporting changes in the usual pattern of chest pain or avoiding fatty foods and exercise does not help the client to avoid an attack; it is more contributory for clients with CAD. In addition, the nurse advises clients to avoid over-the-counter decongestants
When teaching a client with peripheral vascular disease about foot care, a nurse should include which instruction? a) Avoid wearing cotton socks. b) Avoid wearing canvas shoes. c) Avoid using a nail clipper to cut toenails. d) Avoid using cornstarch on the feet.
Avoid wearing canvas shoes. The client should be instructed to avoid wearing canvas shoes. Canvas shoes cause the feet to perspire, and perspiration can cause skin irritation and breakdown. Cotton and cornstarch absorb perspiration. The client should be instructed to cut toenails straight across with nail clippers
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
Blood pressure of 82/40 mm Hg and heart rate of 125 beats/minute Assessment findings that indicate possible bleeding or recurring dissection include hypotension with reflex tachycardia (as evidenced by a blood pressure of 82/40 mm Hg and a heart rate of 125 beats/minute), decreased urine output, and unequal or absent peripheral pulses. Hematuria, increased urine output, and bradycardia aren't signs of bleeding from aneurysm repair or recurring dissection.
A client with suspected lymphoma is scheduled for lymphangiography. The nurse should inform the client that this procedure may cause which harmless temporary change? a) Purplish stools b) Coldness of the soles c) Redness of the upper part of the feet d) Bluish urine
Bluish urine Lymphangiography may turn the urine blue temporarily; it doesn't alter stool color. For several months after the procedure, the upper part of the feet may appear blue, not red. Lymphangiography doesn't affect the soles.
Which of the following observations regarding ulcer formation on the patient's lower extremity indicates that the ulcer is a result of venous insufficiency? a) Is very painful to the patient, even though superficial b) Is deep, involving the joint space c) Border of the ulcer is irregular d) Base is pale to black
Border of the ulcer is irregular The border of an ulcer caused by arterial insufficiency is circular. Superficial venous insufficiency ulcers cause minimal pain. The base of a venous insufficiency ulcer shows beefy red to yellow fibrinous color. Venous insufficiency ulcers are usually superficial.
Which of the following is a characteristic of an arterial ulcer? a) Ankle-brachial index (ABI) > 0.90 b) Border regular and well demarcated c) Edema may be severe d) Brawny edema
Border regular and well demarcated Characteristics of an arterial ulcer include a border that is regular and demarcated. Brawny edema, ABI > 0.90, and edema that may be severe are characteristics of a venous ulcer.
Pentoxifylline (Trental) is a medication used for which of the following conditions? a) Claudication b) Elevated triglycerides c) Hypertension d) Thromboemboli
Claudication Trental and Pletal are the only medications specifically indicated for the treatment of claudication. Thromboemboli, hypertension, and elevated triglycerides are not indications for using Trental.
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
Constant, intense back pain and falling blood pressure Indications of a rupturing abdominal aortic aneurysm include constant, intense back pain; falling blood pressure; and decreasing hematocrit.
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
Contrast phlebography Also known as venography, contrast phlebography involves injecting a radiopaque contrast agent into the venous system. If a thrombus exists, the x-ray image reveals an unfilled segment of vein in an otherwise completely filled 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.
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
Contrast phlebography 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.
Which of the following are characteristics of arterial insufficiency? a) Diminished or absent pulses b) Pulses are present, may be difficult to palpate c) Aching, cramping pain d) Superficial ulcer
Diminished or absent pulses 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
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
Diminished or absent pulses 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
Which of the following aneurysms results in bleeding into the layers of the arterial wall? a) Anastomotic b) Dissecting c) False d) Saccular
Dissecting Dissection results from a rupture in the intimal layer, resulting in bleeding between the intimal and medial layers of the arterial wall. Saccular aneurysms collect blood in the weakened outpouching. In a false aneurysm, the mass is actually a pulsating hematoma. An anastomotic aneurysm occurs as a result of infection at arterial suture or graft sites. (less)
The nurse knows which of the following diagnostic tests are used to document the anatomic site of reflux and provides a quantitative measure of the severity of valvular reflux? a) Duplex ultrasound scan b) Contrast phlebography c) Lymphoscintigraphy d) Lymphangiography
Duplex ultrasound scan Diagnostic tests for varicose veins include the duplex ultrasound scan, which documents the anatomic site of reflux and provides a quantitative measure of the severity of valvular reflux. Contrast phlebography involves injecting a radiopaque contrast agent into the venous system. Lymphoscintigraphy is done when a radioactively labeled colloid is injected subcutaneously in the second interdigital space. The extremity is then exercised to facilitate the uptake of the colloid by the lymphatic system, and serial images are obtained at present intervals. Lymphoangiography provides a way of detecting lymph node involvement resulting from metastatic carcinoma, lymphoma, or infection in sites that are otherwise inaccessible to the examiner except by surgery.
Which of the following statements is accurate regarding Reynaud's disease? a) It affects more than two digits on each hand or foot. b) Episodes may be triggered by unusual sensitivity to cold. c) The disease generally affects the patient bilaterally. d) It is most common in men 16 to 40 years of age.
Episodes may be triggered by unusual sensitivity to cold. Episodes of Reynaud's 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 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.
Episodes may be triggered by unusual sensitivity to cold. Episodes of Raynaud's disease may be triggered by emotional factors or by unusual sensitivity to cold. The disease is most common in women between the ages of 16 and 40. It is generally unilateral and affects only one or two digits.
Which of the following medication classifications lyses and dissolves thrombi? a) Factor XA inhibitors b) Anticoagulant c) Platelet inhibitors d) Fibrinolytic
Fibrinolytic Thrombolytic (fibrinolytic) therapy lyses and dissolves thrombi in 50% of patients. Anticoagulants, platelet inhibitors, and factor XA inhibitors do no lyse or dissolve thrombi.
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
Homans' A positive Homans' sign, or pain in the calf elicited upon flexion of the ankle with the leg straight, indicates the presence of a thrombus. Testing for Romberg's sign assesses cerebellar function. Phalen's test assesses carpal tunnel syndrome. The Rinne test compares air and bone conduction in both ears to screen for or confirm hearing loss.
Which sign or symptom suggests that a client's abdominal aortic aneurysm is extending? a) Elevated blood pressure and rapid respirations b) Decreased pulse rate and blood pressure c) Increased abdominal and back pain d) Retrosternal back pain radiating to the left arm
Increased abdominal and back pain 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.
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
Increased abdominal and back pain 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 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) Risk for injury related to edema c) Ineffective peripheral tissue perfusion related to venous congestion d) Impaired gas exchange related to increased blood flow
Ineffective peripheral tissue perfusion related to venous congestion 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.
Which of the following terms refers to a muscular, cramplike pain in the extremities consistently reproduced with the same degree of exercise and relieved by rest? a) Aneurysm b) Intermittent claudication c) Ischemia d) Bruit
Intermittent claudication Intermittent claudication is a sign of peripheral arterial insufficiency. An aneurysm is a localized sac of an artery wall formed at a weak point in the vessel. A bruit is the sound produced by turbulent blood flow through an irregular, tortuous, stenotic, or dilated vessel. Ischemia is a term used to denote deficient blood supply.
A nurse is teaching a patient newly diagnosed with arterial insufficiency. Which of the following terms should the nurse use to refer to leg pain that occurs when the patient is walking? a) Dyspnea b) Thromboangiitis obliterans c) Orthopnea d) Intermittent claudication
Intermittent claudication Intermittent claudication is leg pain that is brought on by exercise and relieved by rest. Dyspnea is the patient's subjective statement of difficulty breathing. Orthopnea is the inability of the patient to breathe except in the upright (sitting) position. Thromboangiitis obliterans is a peripheral vascular disease also known as Buerger's disease. (less)
Which of the following terms refers to leg pain that is brought on walking and caused by arterial insufficiency? a) Thromboangiitis obliterans b) Intermittent claudication c) Orthopnea d) Dyspnea
Intermittent claudication Intermittent claudication is leg pain that is brought on by exercise and relieved by rest. Dyspnea is the patient's subjective statement of difficulty breathing. Orthopnea is the inability of the patient to breathe except in the upright (sitting) position. Thromboangiitis obliterans is a peripheral vascular disease also known as Burger's disease.
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
Intermittent claudication 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 terms refers to enlarged, red, and tender lymph nodes? a) Lymphadenitis b) Lymphangitis c) Lymphedema d) Elephantiasis
Lymphadenitis Acute lymphadenitis is demonstrated by enlarged, red and tender lymph nodes. Lymphangitis is an 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 completing an assessment on a patient and discovers an enlarged, red, and tender lymph node. The nurse will describe and document the lymph node using which of the following terms? a) Lymphangitis b) Lymphedema c) Lymphadenitis d) Elephantiasis
Lymphadenitis Acute lymphadenitis is demonstrated by enlarged, red, and tender lymph nodes. Lymphangitis is an 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 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? a) Blood pressure every 2 hours b) Color of the leg every 4 hours c) Peripheral pulses every 15 minutes following surgery d) Ankle-arm indices every 12 hours
Peripheral pulses every 15 minutes following surgery 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 patient's status remains stable. (less)
While receiving heparin to treat a pulmonary embolus, a client passes bright red urine. What should the nurse do first? a) Decrease the heparin infusion rate. b) Start an I.V. infusion of dextrose 5% in water (D5W). c) Prepare to administer protamine sulfate. d) Monitor the partial thromboplastin time (PTT).
Prepare to administer protamine sulfate. Frank hematuria indicates excessive anticoagulation and bleeding — and heparin overdose. The nurse should discontinue the heparin infusion immediately and prepare to administer protamine sulfate, the antidote for heparin. Decreasing the heparin infusion rate wouldn't prevent further bleeding. Although the nurse should continue to monitor PTT, this action should occur later. An I.V. infusion of D5W may be administered, but only after protamine has been given.
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
Protamine sulfate Protamine sulfate is the antidote specific to heparin. Phytonadione (vitamin K) is the antidote specific to oral anticoagulants such as warfarin. (Heparin isn't given orally.) Thrombin is a hemostatic agent used to control local bleeding. Plasma protein fraction, a blood derivative, supplies colloids to the blood and expands plasma volume; it's used to treat clients who are in shock
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
Prothrombin time (PT) PT determines a client's response to oral anticoagulant therapy. This test measures the time required for a fibrin clot to form in a citrated plasma sample following addition of calcium ions and tissue thromboplastin and compares this time with the fibrin-clotting time in a control sample. The physician should adjust anticoagulant dosages as needed, to maintain PT at 1.5 to 2.5 times the control value. Bleeding time indicates how long it takes for a small puncture wound to stop bleeding. The platelet count reflects the number of circulating platelets in venous or arterial blood. PTT determines the effectiveness of heparin therapy and helps physicians evaluate bleeding tendencies. Physicians diagnose appoximately 99% of bleeding disorders on the basis of PT and PTT values.
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) Arterial occlusive diseases c) Peripheral vascular disease d) Raynaud's disease
Raynaud's disease 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 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) A history of diabetes mellitus b) Recent pelvic surgery c) An active daily walking program d) History of increased aspirin use
Recent pelvic surgery The client shows signs of deep vein thrombosis (DVT). The pelvic area has a rich blood supply, and thrombophlebitis of the deep veins is associated with pelvic surgery. Aspirin, an antiplatelet agent, and an active walking program help decrease the client's risk of DVT. In general, diabetes mellitus is a contributing factor associated with peripheral vascular disease
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
Stabilizing heart rate and blood pressure and easing anxiety 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 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
Stabilizing heart rate and blood pressure and easing anxiety 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 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.
Stop smoking. 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. Antiembolytic 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.
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? a) Engaging in anaerobic exercise b) Taking daily walks c) Abstaining from foods that increase levels of high-density lipoproteins (HDLs) d) Reducing daily fat intake to less than 45% of total calories
Taking daily walks Taking daily walks relieves symptoms of intermittent claudication, although the exact mechanism is unclear. Anaerobic exercise may make these symptoms worse. Clients with chronic arterial occlusive disease must reduce daily fat intake to 30% or less of total calories. The client should limit dietary cholesterol because hyperlipidemia is associated with atherosclerosis, a known cause of arterial occlusive disease. However, HDLs have the lowest cholesterol concentration, so this client should eat, not abstain from, foods that raise HDL levels.
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.
Teach the patient how to apply a graduated compression stocking. In severe cases of lymphangitis and lymphadenitis with persistent swelling, the nurse teaches the patient how to apply a graduated compression stocking. The nurse informs the physician if the temperature remains elevated. The nurse recommends elevating the area to reduce the swelling and provides warmth to promote comfort and to enhance circulation.
What should the nurse do to manage the persistent swelling in a patient with severe lymphangitis and lymphadenitis? a) Teach the patient how to apply a graduated compression stocking. b) Offer cold applications to promote comfort and to enhance circulation. c) Avoid elevating the area. d) Inform the physician if the temperature remains low.
Teach the patient how to apply a graduated compression stocking. In severe cases of lymphangitis and lymphadenitis with persistent swelling, the nurse teaches the patient how to apply a graduated compression stocking. The nurse informs the physician if the temperature remains elevated. The nurse recommends elevating the area to reduce the swelling and provides warmth to promote comfort and to enhance circulation.
A patient with a diagnosed abdominal aortic aneurysm (AAA) develops severe lower back pain. Which of the following is the most likely cause? a) The patient is experiencing inflammation of the aneurysm. b) The patient is experiencing normal sensations associated with this condition. c) The aneurysm has become obstructed. d) The aneurysm may be preparing to rupture.
The aneurysm may be preparing to rupture. Signs of impending rupture include severe back or abdominal pain, which may be persistent or intermittent. Abdominal pain is often localized in the middle or lower abdomen to the left of the midline. Low back pain may be present because of pressure of the aneurysm on the lumbar nerves. Indications of a rupturing abdominal aortic aneurysm include constant, intense back pain; falling blood pressure; and decreasing hematocrit. Rupture into the peritoneal cavity is rapidly fatal. A retroperitoneal rupture of an aneurysm may result in hematomas in the scrotum, perineum, flank, or penis.
A patient is receiving enoxaparin (Lovenox) and warfarin (Coumadin) therapy for a venous thromboembolism (VTE). Which lab value indicates that anticoagulation is adequate and enoxaparin (Lovenox) can be discontinued? a) The patient's activated partial thromboplastin time (aPPT) is half of the control value. b) The patient's K+ level is 3.5. c) The patient's prothrombin time (PT) is 0.5 times normal. d) The patient's international normalized ratio (INR) is 2.5.
The patient's international normalized ratio (INR) is 2.5. Oral anticoagulants, such as warfarin, are monitored by the PT or the INR. Because the full anticoagulant effect of warfarin is delayed for 3 to 5 days, it is usually administered concurrently with heparin until desired anticoagulation has been achieved (ie, when the PT is 1.5 to 2 times normal or the INR is 2.0 to 3.0)
A client with venous insufficiency develops varicose veins in both legs. Which statement about varicose veins is accurate? a) The severity of discomfort isn't related to the size of varicosities. b) Sclerotherapy is used to cure varicose veins. c) Primary varicose veins are caused by deep vein thrombosis (DVT) and inflammation. d) Varicose veins are more common in men than in women.
The severity of discomfort isn't related to the size of varicosities. Clients with varicose veins commonly complain of aching, heaviness, itching, moderate swelling, and unsightly appearance of the legs. However, the severity of discomfort is hard to assess and seems unrelated to the size of varicosities. Varicose veins are more common in women than in men. Primary varicose veins typically result from a congenital or familial predisposition that makes the vein wall less elastic; secondary varicosities occur when trauma, obstruction, DVT, or inflammation damages valves. Sclerotherapy, in which a sclerosing agent is injected into a vein, is used to treat varicose veins; it doesn't cure them.
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
Thoracic area 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.
What are the symptoms a nurse should assess for in a patient with lymphedema as a result of impaired nutrition to the tissue? a) Loose and wrinkled skin b) Ulcers and infection in the edematous area c) Cyanosis d) Evident scaring
Ulcers and infection in the edematous area In a patient with lymphedema, the tissue nutrition is impaired from the stagnation of lymphatic fluid, leading to ulcers and infection in the edematous area. Later, the skin also appears thickened, rough, and discolored. Scaring does not occur in patients with lymphedema, and cyanosis is a bluish discoloration of the skin and mucous membranes
What are the symptoms a nurse should assess for in a patient with lymphedema as a result of impaired nutrition to the tissue? a) Loose and wrinkled skin b) Ulcers and infection in the edematous area c) Evident scarring d) Cyanosis
Ulcers and infection in the edematous area In a patient with lymphedema, the tissue nutrition is impaired from 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 patients with lymphedema, and cyanosis is a bluish discoloration of the skin and mucous membranes.
The nurse teaches the patient with peripheral vascular disease (PVD) to refrain from smoking because nicotine causes which of the following? a) Slowed heart rate b) Vasospasm c) Diuresis d) Depression of the cough reflex
Vasospasm Nicotine causes vasospasm and can thereby dramatically reduce circulation to the extremities. Tobacco smoke also impairs transport and cellular use of oxygen and increases blood viscosity. Patients with arterial insufficiency who smoke or chew tobacco must be fully informed of the effects of nicotine on circulation and be encouraged to stop.
The nurse is caring for a client who is scheduled to have a vein ligation in the morning. How would you describe a vein ligation to the client? a) Removal of the great saphenous vein. b) Removal of the small saphenous vein. c) Veins are tied off and removed. d) Veins are tied off and left in the leg.
Veins are tied off and left in the leg. A vein ligation is a procedure in which the affected veins are ligated (tied off) above and below the area of incompetent valves, but the dysfunctional vein remains. A vein stripping is the removal of the veins after being tied off.
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
Venous insufficiency Symptoms of venous insufficiency include present pedal pulses, edema, pigmentation in gater area, and a reddish blue color. Ulcers caused by venous insufficiency will be irregular in shape and usually located around the ankles or the anterior tibial area. Characteristics of arterial insufficiency ulcers include location at the tips of the toes, great pain, and circular shape with a pale to black ulcer base.
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) a lymphoscintigraphy. b) a contrast phlebography. c) an air plethysmography. d) a lymphangiography.
a contrast phlebography. 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.
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.
a vasospasm. Nicotine causes vasospasm and can thereby dramatically reduce circulation to the extremities. Nicotine has stimulant effects. Nicotine does not suppress cough. Smoking irritates the bronchial tree, causing coughing. Nicotine does not cause diuresis.
The most common site of aneurysm formation is in the: a) abdominal aorta, just below the renal arteries. b) aortic arch, around the ascending and descending aorta. c) ascending aorta, around the aortic arch. d) descending aorta, beyond the subclavian arteries.
abdominal aorta, just below the renal arteries. About 75% of aneurysms occur in the abdominal aorta, just below the renal arteries (Debakey type I aneurysms). Debakey type II aneurysms occur in the aortic arch around the ascending and descending aorta, whereas Debakey type III aneurysms occur in the descending aorta, beyond the subclavian arteries
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) dependent pallor. b) no rubor for 10 seconds after the maneuver. c) elevational rubor. d) a 30-second filling time for the veins.
dependent pallor. If arterial insufficiency is present, elevation of the limb would yield a pallor from the lack of circulation. Rubor and increased venous filling time would suggest venous problems secondary to venous trapping and incompetent valves.
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) encouraging ambulation to prevent pooling of blood. c) forcing blood into the deep venous system. d) elevating the extremity to prevent pooling of blood.
forcing blood into the deep venous system. 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 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) shave the affected leg in anticipation of surgery. b) keep the affected leg level or slightly dependent. c) elevate the affected leg as high as possible. d) place a heating pad around the affected calf.
keep the affected leg level or slightly dependent. While the physician makes treatment decisions, the nurse should maintain the client on bed rest, keeping the affected leg level or slightly dependent (to aid circulation) and protecting it from pressure and other trauma. Warming the leg with a heating pad (or chilling it with an ice pack) would further compromise tissue perfusion and increase injury to the leg. Elevating the leg would worsen tissue ischemia. Shaving an ischemic leg could cause accidental trauma from cuts or nicks.
Vasodilation or vasoconstriction produced by an external cause will interfere with a nurse's accurate assessment of a client with peripheral vascular disease (PVD). Therefore, the nurse should: a) maintain room temperature at 78° F (25.6° C). b) keep the client uncovered. c) match the room temperature to the client's body temperature. d) keep the client warm.
keep the client warm. The nurse should keep the client covered and expose only the portion of the client's body that she's assessing. The nurse should also keep the client warm by maintaining his room temperature between 68° F and 74° F (20° and 23.3° C). Extreme temperatures aren't good for clients with PVD. The valves in their arteries and veins are already insufficient, and exposing them to vast changes in temperature could affect assessment findings. Keeping the client uncovered would cause him to become chilled. Matching the room temperature to the client's body temperature is inappropriate.
Which of the following are indications of a rupturing aortic aneurysm? Select all that apply. a) Decreasing hematocrit b) Increasing hematocrit c) Decreasing blood pressure d) Increasing blood pressure e) Constant, intense back pain
• Decreasing hematocrit • Decreasing blood pressure • Constant, intense back pain Indications of a rupturing abdominal aneurysm include constant, intense back pain; falling blood pressure; and decreasing hematocrit.
