ASSESSMENT AND MANAGEMENT OF PATIENTS WITH VASCULAR DISORDERS AND DISORDERS OF PERIPHERAL CIRCULATION (CH. 26) PREPU

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

A nurse is assessing a client's right lower leg, which is wrapped with an elastic bandage. Which signs and symptoms suggest circulatory impairment?

Numbness, cool skin temperature, and pallor

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.

What should the nurse do to manage the persistent swelling in a client with severe lymphangitis and lymphadenitis?

Teach the client how to apply an elastic sleeve

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

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.

Which of the following is the hallmark symptom for peripheral arterial disease (PAD) in the lower extremity?

Intermittent claudication

Aortic dissection may be mistaken for which of the following disease processes?

Myocardial infarction (MI)

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?

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

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."

Which of the following is accurate regarding the effects of nicotine and tobacco smoke on the body? Select all that apply

- Causes vasospasm - Reduces circulation to the extremities - Impairs transport and cellular use of oxygen - Increases blood viscosity

Which of the following are indications of a rupturing aortic aneurysm? Select all that apply.

- Constant, intense back pain - Decreasing blood pressure - Decreasing hematocrit

The physician prescribed a Tegapore dressing to treat a venous ulcer. What should the nurse expect that the ankle-brachial index (ABI) will be if the circulatory status is adequate?

0.50

Heparin therapy is usually considered therapeutic when the activated partial thromboplastin time (aPTT) is how many times higher than a normal value?

1.5 to 2.5

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

Approximately what percentage of the arterial lumen must be obstructed before intermittent claudication is experienced?

50

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.

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 educating a patient with chronic venous insufficiency about prevention of complications related to the disorder. What should the nurse include in the information given to the patient? (Select all that apply.) (3)

Avoid constricting garments. Elevate the legs above the heart level for 30 minutes every 2 hours. Sleep with the foot of the bed elevated about 6 inches.

Which of the following assessment results is considered a major risk factor for PAD?

BP of 160/110 mm Hg

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:

Cigarette smoking.

A health care provider wants a cross-sectional image of the abdomen to evaluate the degree of stenosis in a patient's left common iliac artery. The nurse knows to prepare the patient for which of the following?

Computed tomography angiography (CTA)

Which aneurysm results in bleeding into the layers of the arterial wall?

Dissecting

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

The nurse plans care for a client who is newly diagnosed with peripheral artery disease (PAD). For each nursing action, click to specify if the intervention is appropriate to increase the arterial blood supply to the client's extremities or to promote vasodilation and prevent vascular compression.

Increase Arterial Blood Supply to the Extremities - Keep legs in a dependent position. - Increase in physical activity each day. Promote Vasodilation and Prevent Vascular Compression - Wear warm clothing in the winter. - Do not use of bicotine products. - Avoid crossing the legs.

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

With a severe degree of peripheral arterial insufficiency, leg pain during rest can be reduced by:

Lowering the limb so that it is dependent. Explanation: Lowering the extremity to a dependent position improves perfusion to the distal tissues.

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 patient complains of a "stabbing pain and a burning sensation" in his left foot. The nurse notices that the foot is a lighter color than the rest of the skin. The artery that the nurse suspects is occluded would be the:

Posterior tibial.

Which of the following is the most effective intervention for preventing progression of vascular disease?

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?

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.

The nurse is educating a patient with chronic venous insufficiency about prevention of complications related to the disorder. What should the nurse include in the information given to the patient? (Select all that apply.)

Taking daily walks

What should the nurse do to manage persistent swelling in a client with severe lymphangitis and lymphadenitis?

Teach the client how to apply a graduated compression stocking.

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 nurse is caring for a patient with venous insufficiency. For what should the nurse assess the patient'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

A home health nurse is seeing an elderly male client for the first time. During the physical assessment of the skin on the lower legs, the nurse notes edema, brown pigmentation in the gaiter area, pedal pulses, and a few irregularly shaped ulcers around the ankles. From these findings, the nurse knows that the client has a problem with peripheral circulation. Which of the following does the nurse suspect?

Venous insufficiency

A client reports pain and cramping in the thigh when climbing stairs and numbness in the legs after exertion. Which diagnostic test with the physician likely perform right in the office to determine PAD?

ankle-brachial index

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 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:

keep the affected leg level or slightly dependent.

Which class of medication lyses and dissolves thrombi?

Fibrinolytic

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

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?

Veins are tied off and left in the leg.