nursing 6 unit 5 Brunner Chapter 30- Assessment and Management of Patients With Vascular Disorders and Problems of Peripheral Circulation

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

"I will need to stop smoking because the nicotine causes less blood to flow to my hands and feet." Explanation: 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) "A heating pad to your feet is a good idea because it increases the metabolic rate." b) "It is better to soak your feet in hot water as long as the water temperature is below 110 degrees F." 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." Explanation: 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.

When administering heparin anticoagulant therapy, the nurse needs to make certain that the activated partial thromboplastin time (aPTT) is within the therapeutic range of: a) 4.5 times the baseline control. b) 1.5 to 2.5 times the baseline control. c) 3.5 times the baseline control. d) 2.5 to 3.0 times the baseline control.

1.5 to 2.5 times the baseline control. Correct Explanation: A normal PTT level is 21 to 35 seconds. A reading of more than 100 seconds indicates a significant risk of hemorrhage.

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) 30 b) 20 c) 40 d) 50

50 Explanation: The distal outflow vessel must be at least 50% patent for the graft to remain patent.

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

A vasospasm. Explanation: 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.

Which of the following diagnostic tests are used to quantify venous reflux and calf muscle pump ejection? a) Contrast phlebography b) Lymphangiography c) Lymphoscintigraphy d) Air plethysmography

Air plethysmography Explanation: 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.

The nurse explains to a patient that the primary cause of a varicose vein is: a) Venous occlusion. b) Phlebothrombosis. c) An incompetent venous valve. d) Venospasm.

An incompetent venous valve. Explanation: Varicose veins are abnormally dilated, tortuous, superficial veins caused by incompetent venous valves.

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) Inside of the ankle just above the heel. c) Outside of the foot just below the heel. d) Exterior surface of the foot near the heel.

Anterior surface of the foot near the ankle joint. Correct Explanation: The dorsalis pedis pulse can be palpated on the dorsal surface of the foot distal to the major prominence of the navicular bone. Refer to Figure 18-3 in the text.

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

Arterial insufficiency Explanation: 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 Explanation: Atherosclerosis is the most common cause of peripheral arterial problems in the older adult. Therefore, options A, B, and D are incorrect

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) Redness of the upper part of the feet c) Coldness of the soles d) Bluish urine

Bluish urine Explanation: 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 is a characteristic of an arterial ulcer? a) Edema may be severe b) Border regular and well demarcated c) Brawny edema d) Ankle-brachial index (ABI) > 0.90

Border regular and well demarcated Correct Explanation: 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) Elevated triglycerides b) Claudication c) Hypertension d) Thromboemboli

Claudication Explanation: 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 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? a) Doppler ultrasound b) Magnetic resonance angiography (MRA) c) Angiography d) Computed tomography angiography (CTA)

Computed tomography angiography (CTA) Explanation: A CTA is used to visualize arteries and veins and help assess for stenosis and occlusion.

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) Higher than normal blood pressure and falling hematocrit c) Constant, intense back pain and falling blood pressure d) Constant, intense headache and falling blood pressure

Constant, intense back pain and falling blood pressure Explanation: Indications of a rupturing abdominal aortic aneurysm include constant, intense back pain; falling blood pressure; and decreasing hematocrit.

As the clinic nurse caring for a client with varicose veins, what is an appropriate nursing action for this client? a) Demonstrate how to apply and remove elastic support stockings. b) Demonstrate how to self-administer IV infusions. c) Assess for the sites of bleeding. d) Assess for skin integrity.

Demonstrate how to apply and remove elastic support stockings. Explanation: The nurse demonstrates how to apply and remove elastic support stockings. Varicose veins do not require the nurse to demonstrate how to self-administer IV infusions. Varicose veins require the client to elevate legs regularly and perform leg exercises. However, it does not involve bleeding or skin lesions.

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

Diminished or absent pulses Explanation: 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.

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

Dissecting Explanation: 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

Which of the following medication classifications lyses and dissolves thrombi? a) Fibrinolytic b) Platelet inhibitors c) Factor XA inhibitors d) Anticoagulant

Fibrinolytic Correct Explanation: Thrombolytic (fibrinolytic) therapy lyses and dissolves thrombi in 50% of patients. Anticoagulants, platelet inhibitors, and factor XA inhibitors do no lyse or dissolve thrombi.

Providing postoperative care to a patient who has percutaneous transluminal angioplasty (PTA), with insertion of a stent, for a femoral artery lesion, includes assessment for the most serious complication of: a) Decreased motor function. b) Thrombosis of the graft. c) Stent dislodgement. d) Hemorrhage.

Hemorrhage. Explanation: All choices are serious and require medical/surgical intervention. However, hemorrhage is the most serious complication that requires immediate attention.

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) Rinne b) Homans' c) Romberg's d) Phalen's

Homans' Correct Explanation: 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.

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

In 3 to 5 days Correct Explanation: 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 (i.e., when the PT is 1.5 to 2 times normal or the INR is 2.0 to 3.0) (Holbrook et al., 2012).

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

Myocardial infarction (MI) Correct Explanation: 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 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) Moderate to severe arterial insufficiency c) Tissue loss to that foot d) Very mild arterial insufficiency

Moderate to severe arterial insufficiency Explanation: 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.

The nurse is performing wound care for a patient with a necrotic sacral wound. The prescribed treatment is isotonic saline solution with fine mesh gauze and a dry dressing to cover. What type of debridement is the nurse performing? a) Enzymatic debridement b) Selective debridement c) Nonselective debridement d) Surgical debridement

Nonselective debridement Explanation: Nonselective débridement can be accomplished by applying isotonic saline dressings of fine mesh gauze to the ulcer. When the dressing dries, it is removed (dry), along with the debris adhering to the gauze. Pain management is usually necessary.

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) Peripheral pulses every 15 minutes following surgery b) Ankle-arm indices every 12 hours c) Color of the leg every 4 hours d) Blood pressure every 2 hours

Peripheral pulses every 15 minutes following surgery Correct Explanation: 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

When assessing a client with cellulitis of the right leg, which finding should the nurse expect to observe? a) Painful skin that is swollen and pale in color b) Cold, red skin c) Red, swollen skin with inflammation spreading to surrounding tissues d) Small, localized blackened area of skin

Red, swollen skin with inflammation spreading to surrounding tissues Correct Explanation: Cellulitis, an inflammation of soft tissues, can extend to surrounding tissues. The skin becomes reddened, warm, swollen, and sometimes painful. The skin wouldn't be cold, pale, or necrotic.

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. Explanation: 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 aneurysm may be preparing to rupture. c) The patient is experiencing normal sensations associated with this condition. d) The aneurysm has become obstructed.

The aneurysm may be preparing to rupture. Explanation: 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 international normalized ratio (INR) is 2.5. b) The patient's K+ level is 3.5. c) The patient's activated partial thromboplastin time (aPPT) is half of the control value. d) The patient's prothrombin time (PT) is 0.5 times normal.

The patient's international normalized ratio (INR) is 2.5. Explanation: 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)

The most important factor regulating the caliber of blood vessels, which determines resistance to flow, is: a) The influence of circulating chemicals. b) Independent arterial wall activity. c) The sympathetic nervous system. d) Hormonal secretion.

The sympathetic nervous system. Explanation: Stimulation of the sympathetic nervous system causes vasoconstriction thus regulating blood flow. Norepinephrine is the responsible neurotransmitter.

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

Thoracic area Explanation: 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.

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) an air plethysmography. c) a lymphangiography. d) a contrast phlebography.

You selected: a contrast phlebography. Correct Explanation: 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) a slowed heart rate. b) diuresis. c) depression of the cough reflex. d) a vasospasm.

a vasospasm. Explanation: 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) aortic arch, around the ascending and descending aorta. b) abdominal aorta, just below the renal arteries. c) ascending aorta, around the aortic arch. d) descending aorta, beyond the subclavian arteries.

abdominal aorta, just below the renal arteries. Explanation: 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) a 30-second filling time for the veins. c) no rubor for 10 seconds after the maneuver. d) elevational rubor.

dependent pallor. Explanation: 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) elevating the extremity to prevent pooling of blood. b) providing warmth to the extremity. c) forcing blood into the deep venous system. d) encouraging ambulation to prevent pooling of blood.

forcing blood into the deep venous system. Explanation: 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) keep the affected leg level or slightly dependent. b) shave the affected leg in anticipation of surgery. 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. Explanation: 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) keep the client warm. d) match the room temperature to the client's body temperature.

keep the client warm. Explanation: 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) Constant, intense back pain b) Decreasing hematocrit c) Decreasing blood pressure d) Increasing hematocrit e) Increasing blood pressure

• Constant, intense back pain • Decreasing blood pressure • Decreasing hematocrit Explanation: Indications of a rupturing abdominal aneurysm include constant, intense back pain; falling blood pressure; and decreasing hematocrit.

Which of the following are complications of percutaneous transluminal balloon angioplasty (PTA)? Select all that apply. a) Hematoma b) Embolization c) Bleeding d) Stent migration e) Dissection of the vessel

• Hematoma • Embolization • Dissection of the vessel • Bleeding • Stent migration Explanation: Complications from PTA include hematoma, embolization dissection of the vessel, bleeding, intimal damage (dissection), and stent migration.

A nurse assesses a patient for a possible abdominal aortic aneurysm (AAA). Which of the following signs would the nurse recognize as positive indicators? Select all that apply. a) Low back pain b) An abdominal pulsatile mass c) Hypertension d) Lower abdominal pain e) Radiating chest pain f) A systolic bruit

• Low back pain • Lower abdominal pain • An abdominal pulsatile mass • A systolic bruit Explanation: Chest pain and hypertension, although they may be present, are not indicators of AAA even if present. All other choices are positive.

Which of the following are alterations noted in Virchow's triad? Select all that apply. a) Vessel wall injury b) Stasis of blood c) Tenderness d) Edema e) Altered coagulation

• Stasis of blood • Altered coagulation • Vessel wall injury Correct Explanation: Three factors, known as Virchow's triad, are believed to play a significant role in the development of venous thrombosis. They are stasis of blood, vessel wall injury, and altered coagulation. Edema and tenderness are clinical manifestations of venous thrombosis, but are not part of the triad.