PDV Brunner
Aortic dissection may be mistaken for which of the following disease processes?
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.
Which is a risk factor for venous disorders of the lower extremities?
Obesity
Which risk factor is related to venous stasis for deep vein thrombosis (DVT) and pulmonary embolism (PE)?
Obesity
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:
left calf circumference 1" (2.5 cm) larger than the right
required
means that the client needs to have surgery, and it should be planned within a few weeks or months
urgent
means that the client requires prompt attention within 24 to 30 hours
elective
means that there is an indication for surgery, but failure to have surgery will not be catastrophic
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?
Contrast phlebography
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?
Homans'
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
emergency
that the client requires immediate attention and the disorder may be life threatening
Hyperglycemia, which can increase the risk of surgical wound infection, may result from
the stress of surgery, which can trigger increased levels of catecholamine
A community health nurse teaches a group of older adults 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 statement?
"I will need to stop smoking because the nicotine causes less blood to flow to my hands and feet."
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."
The nurse is monitoring a patient who is on heparin anticoagulant therapy. What should the nurse determine the therapeutic range of the international normalized ratio (INR) should be? 2.0-3.0 7.0-8.0 5.0-6.0 4.0-5.0
2.0 - 3.0
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 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?
Arterial insufficiency
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
A client is recovering from surgical repair of a dissecting aortic aneurysm. Which assessment findings indicate possible bleeding or recurring dissection? Blood pressure of 82/40 mm Hg and heart rate of 125 beats/minute Urine output of 15 ml/hour and 2+ hematuria Blood pressure of 82/40 mm Hg and heart rate of 45 beats/minute Urine output of 150 ml/hour and heart rate of 45 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.
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
Contrast phlebography
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 is a characteristic of arterial insufficiency?
Diminished or absent pulses
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 aneurysm results in bleeding into the layers of the arterial wall?
Dissecting
A patient who had a colon resection 3 days ago is complaining of discomfort in the left calf. How should the nurse assess Homan's sign to determine if the patient may have a thrombus formation in the leg?
Dorsiflex the foot while the leg is elevated to check for calf pain.
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.
Which observation regarding ulcer formation on the client's lower extremity indicates to the nurse that the ulcer is a result of venous insufficiency?
Large and superficial Ulcerations are in the area of the medial or lateral malleolus (gaiter area) and are typically large, superficial, and highly exudative. Superficial venous insufficiency ulcers cause minimal pain. The base of a venous insufficiency ulcer shows a beefy red to yellow fibrinous color.
Which class of medication lyses and dissolves thrombi?
Fibrinolytic Thrombolytic (fibrinolytic) therapy lyses and dissolves thrombi in 50% of clients. Anticoagulants, platelet inhibitors, and factor XA inhibitors do not lyse or dissolve thrombi.
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 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 is the hallmark symptom for peripheral arterial disease (PAD) in the lower extremity?
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.
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. Oral anticoagulants such as warfarin are monitored by 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)
A nurse is completing an assessment on a client and discovers an enlarged, red, and tender lymph node. The nurse will describe and document the lymph node using which term?
Lymphadenitis Acute lymphadenitis is demonstrated by enlarged, red, and tender lymph nodes. Lymphangitis is 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 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 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 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?
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?
Prothrombin time (PT) ( PROthrombin = PROactive)
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?
Raynaud's disease
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
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
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
The most important factor regulating the caliber of blood vessels, which determines resistance to flow, is:
The sympathetic nervous system. 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?
Thoracic area
The nurse is caring for a patient with venous insufficiency. What should the nurse assess the patient's lower extremities for?
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 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?
Venous insufficiency
The most common site of aneurysm formation is in the:
abdominal aorta, just below the renal arteries
Clients who have received corticosteroids are at risk of
adrenal insufficiency
The patient with diabetes who is undergoing surgery is at risk for
hypoglycemia and hyperglycemia
Hypoglycemia may develop during anesthesia or postoperatively from
inadequate carbohydrates or excessive administration of insulin.
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.
General risk factors are related to age
nutritional status, use of alcohol, tobacco/other , physical condition
