Chapter 17 Prep U Questions

The nurse instructs a client with Raynaud phenomenon on actions to improve the symptoms. Which client statement indicates the need for additional instruction?

"I will limit the amount of cigarettes I smoke."

The nurse is caring for a client with venous insufficiency. For what should the nurse assess the client's lower extremities?

Ulceration

What symptoms should the nurse assess for in a client with lymphedema as a result of impaired nutrition to the tissue?

Ulcers and infection in the edematous area

The nurse is caring for a client who has started anticoagulant therapy with warfarin (Coumadin). When does the nurse understand that therapeutic benefits will begin?

In 3 to 5 days

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

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?

International normalized ratio (INR) is 2.5

The nurse is caring for a client with peripheral arterial insufficiency. What can the nurse suggest to help relieve leg pain during rest?

Lowering the limb so that it is dependent

The nurse is caring for a client who returned from the tropics 2 weeks ago. The client has been diagnosed with lymphangitis and is experiencing lymphedema. You are aware that the lymphedema may be due to what?

Obstructed lymph vessels

A client who is diagnosed with Raynaud syndrome reports cold and numbness in the fingers. Which finding should the nurse identify as an early sign of vasoconstriction?

Pallor

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?

Participate in a regular walking program

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?

Peripheral pulses every 15 minutes after surgery

A client 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 client should consequently prioritize what assessments?

Assessing the client for internal or external hemorrhage

A home health nurse is seeing an older adult 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?

Venous insufficiency

A community health nurse is providing an educational event at the local seniors' center. The topic the nurse is speaking about is varicose veins. What would the nurse suggest as proactive preventative measure for varicose veins?

Walking for several minutes every hour to promote circulation

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

Nursing management of a client receiving heparin includes monitoring for heparin-induced thrombocytopenia. Choose the result that indicates the potential for spontaneous intracranial hemorrhage, which is life-threatening. A platelet count of:

10,000 to 14,500 mm3

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?

50

A pregnant client who developed deep vein thrombosis (DVT) in the right leg is receiving heparin I.V. on the medical floor. Physical therapy is ordered to maintain mobility and prevent additional DVT. An unlicensed assistive personnel (UAP) 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

Which assessment finding by the nurse is the most significant finding suggestive of aortic aneurysm?

Abdomen bruit

A client 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:

Alteplase

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

Aphonia Brassy cough Hoarse voice Stridor

A nurse in a long-term care facility is caring for an 83-year-old client who has a history of heart failure (HF) and peripheral arterial disease (PAD). At present, the client is unable to stand or ambulate. The nurse should implement measures to prevent which complication?

Deep vein thrombosis

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 assessing a client who has arterial insufficiency of the legs and an ulcer on the left great toe would expect to find which characteristic?

Diminished or absent pulses

Which is a characteristic of arterial insufficiency?

Diminished or absent pulses

A client who had a colon resection 3 days ago reports discomfort in the left calf. How should the nurse assess Homan's sign to determine if the client may have a thrombus formation in the leg?

Dorsiflex the foot while the leg is elevated to check for calf pain

When caring for a client with leg ulcers, the positioning of the legs depends on whether the client's ulcer is arterial or venous in origin. How should the nurse position a client who has leg ulcers that are venous in origin?

Elevate the client's lower extremities

A nurse and health care provider are preparing to visit a hospitalized client with peripheral arterial disease. As they approach the client's room, the health care provider asks if the client has reported any intermittent claudication. The client has reported this symptom. The nurse explains to the health care provider which of the following details?

The client can walk about 50 feet before getting pain in the right lower leg

A client with systemic lupus erythematosus (SLE) reports that their 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 client is readmitted to the facility with a warm, tender, reddened area on their right calf. Which contributing factor should the nurse recognize as most important?

Recent pelvic surgery

A client has sought care from their health care provider, stating, "The front of my foot aches constantly these days, and it's gotten so bad that it keeps me up at night." The nurse should recognize that this client may be experiencing the symptoms of:

Severe arterial insufficiency

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?

Severe pain

A health care provider 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 they formulate 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 health care provider, a client with chronic arterial occlusive disease reports that they have 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

A client with a diagnosed abdominal aortic aneurysm (AAA) develops severe lower back pain. Which 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

A nurse is instructing a client about using antiembolism stockings. Antiembolism stockings help prevent deep vein thrombosis (DVT) by:

forcing blood into the deep venous system