AH3-Exam3 DVT/STROKE NCLEX

The nurse is caring for the client with chronic venous insufficiency. Which statement indicates the client understands the discharge teaching? 1. "I shouldn't cross my legs for more than 15 minutes." 2. "I need to elevate the foot of my bed while sleeping." 3. "I should take a baby aspirin every day with food." 4. "I should increase my fluid intake to 3,000 mL a day."

2. "I need to elevate the foot of my bed while sleeping." Rationale: 2. Elevating the foot of the bed while sleeping helps the venous blood return to the heart and decreases pressure in the lower extremity.

The client diagnosed with a DVT is placed on a medical unit. Which nursing interventions should be implemented? Select all that apply. 1. Place sequential compression devices on both legs. 2. Instruct the client to stay in bed and not ambulate. 3. Encourage fluids and a diet high in roughage. 4. Monitor IV site every four (4) hours and prn. 5. Assess Homans' sign every 24 hours.

2. Instruct the client to stay in bed and not ambulate. 3. Encourage fluids and a diet high in roughage. 4. Monitor IV site every four (4) hours and prn. Rationale: 1. Sequential compression devices provide gentle compression of the legs to prevent DVT, but they are not used to treat DVT because the compressions could cause the clot to break loose. 2. Clients should be on bedrest for five (5) to seven (7) days after diagnosis to allow time for the clot to adhere to the vein wall, thereby preventing embolization. 3. Bedrest and limited activity predispose the client to constipation. Fluids and diets high in fiber will help prevent constipation. Fluids will also help provide adequate fluid volume in the vasculature. 4. The client will be administered a heparin IV drip, which should be monitored. 5. Homans' sign is assessed to determine if a DVT is present. This client has already been diagnosed with a DVT. Manipulating the leg to determine the presence of Homans' sign could dislodge the clot.

The client comes to the clinic complaining of muscle cramping and pain in both legs when walking for short periods of time. Which medical term would the nurse document in the client's record? 1. Peripheral vascular disease. 2. Intermittent claudication. 3. Deep vein thrombosis. 4. Dependent rubor.

2. Intermittent claudication. Rationale: This is the classic symptom of arterial occlusive disease. The test taker could eliminate options "1" and "3" as possible answers if the words "medical term" were noted. Both options "1" and "3" are disease processes, not medical terms.

The nurse is assessing a client experiencing motor loss as a result of a left-sided cerebrovascular accident (CVA). Which clinical manifestation would the nurse document? 1. Hemiparesis of the client's left arm and apraxia. 2. Paralysis of the right side of the body and ataxia. 3. Homonymous hemianopsia and diplopia. 4. Impulsive behavior and hostility toward family.

2. Paralysis of the right side of the body and ataxia. Rationale: The most common motor dysfunction of a CVA is paralysis of one side of the body, hemiplegia; in this case with a left-sided CVA, the paralysis would affect the right side. Ataxia is an impaired ability to coordinate movement.

Which client would the nurse identify as being most at risk for experiencing a cerebrovascular accident (CVA)? 1. A 55-year-old African American male. 2. An 84-year-old Japanese female. 3. A 67-year-old Caucasian male. 4. A 39-year-old pregnant female.

1. A 55-year-old African American male. Rationale: African Americans have twice the rate of CVAs as Caucasians and men have a higher incidence than women; African Americans also suffer more extensive damage from a CVA than do people of other cultural groups.

Which assessment data would support that the client has a venous stasis ulcer? 1. A superficial pink open area on the medial part of the ankle. 2. A deep pale open area over the top side of the foot. 3. A reddened blistered area on the heel of the foot. 4. A necrotic gangrenous area on the dorsal side of the foot.

1. A superficial pink open area on the medial part of the ankle. Rationale: The medial part of the ankle usually ulcerates because of edema that leads to stasis, which, in turn, causes the skin to break down.

A client diagnosed with a subarachnoid hemorrhage has undergone a craniotomy for repair of a ruptured aneurysm. Which intervention will the intensive care nurse implement? 1. Administer a stool softener bid. 2. Encourage the client to cough hourly. 3. Monitor neurological status every shift. 4. Maintain the dopamine drip to keep BP at 160/90.

1. Administer a stool softener bid. Rationale: The client is at risk for increased intracranial pressure whenever performing the Valsalva maneuver, which will occur when straining during defecation. Therefore, stool softeners would be appropriate

The client diagnosed with atrial fibrillation has experienced a transient ischemic attack (TIA). Which medication would the nurse anticipate being ordered for the client on discharge? 1. An oral anticoagulant medication. 2. A beta blocker medication. 3. An anti-hyperuricemic medication. 4. A thrombolytic medication.

1. An oral anticoagulant medication. Rationale: The nurse would anticipate an oral anticoagulant, warfarin (Coumadin), to be prescribed to help prevent thrombi formation in the atria secondary to atrial fibrillation. The thrombi can become embolic and may cause a TIA or CVA (stroke).

The nurse is completing a neurovascular assessment on the client with chronic venous insufficiency. What should be included in this assessment? Select all that apply. 1. Assess for paresthesia. 2. Assess for pedal pulses. 3. Assess for paralysis. 4. Assess for pallor. 5. Assess for polar (temperature).

1. Assess for paresthesia. 2. Assess for pedal pulses. 3. Assess for paralysis. 4. Assess for pallor. 5. Assess for polar (temperature). Rationale: 1. The nurse should determine if the client has any numbness or tingling. 2. The nurse should determine if the client has pulses, the presence of which indicates there is no circulatory compromise. 3. The nurse should determine if the client can move the feet and legs. 4. The nurse should determine if the client's feet are pink or pale. 5. The nurse should assess the feet to determine if they are cold or warm. TEST-TAKING HINT: These five (5) assessment interventions, along with assessing for pain, are known as the 6 Ps, which is the neurovascular assessment.

The client diagnosed with a DVT is on a heparin drip at 1,400 units per hour, and Coumadin (warfarin sodium, also an anticoagulant) 5 mg daily. Which intervention should the nurse implement first? 1. Check the PTT and PT/INR. 2. Check with the HCP to see which drug should be discontinued. 3. Administer both medications. 4. Discontinue the heparin because the client is receiving Coumadin.

1. Check the PTT and PT/INR. Rationale: The nurse should check the laboratory values pertaining to the medications before administering the medications. The client will be administered an oral medication while still receiving a heparin drip to allow time for the client to achieve a therapeutic level of the oral medication before discontinuing the heparin. The effects of oral medications take three (3) to five (5) days to become therapeutic.

The nurse is unable to assess a pedal pulse in the client diagnosed with arterial occlusive disease. Which intervention should the nurse implement first? 1. Complete a neurovascular assessment. 2. Use the Doppler device. 3. Instruct the client to hang the feet off the side of the bed. 4. Wrap the legs in a blanket.

1. Complete a neurovascular assessment. Rationale: An absent pulse is not uncommon in a client diagnosed with arterial occlusive disease, but the nurse must ensure that the feet can be moved and are warm, which indicates adequate blood supply to the feet.

The nurse is assessing the client diagnosed with long-term arterial occlusive disease. Which assessment data support the diagnosis? 1. Hairless skin on the legs. 2. Brittle, flaky toenails. 3. Petechiae on the soles of feet. 4. Nonpitting ankle edema.

1. Hairless skin on the legs. Rationale: The decreased oxygen over time causes the loss of hair on the tops of the feet and ascending both legs.

The client diagnosed with a right-sided cerebrovascular accident is admitted to the rehabilitation unit. Which interventions should be included in the nursing care plan? Select all that apply. 1. Position the client to prevent shoulder adduction. 2. Turn and reposition the client every shift. 3. Encourage the client to move the affected side. 4. Perform quadriceps exercises three (3) times a day. 5. Instruct the client to hold the fingers in a fist.

1. Position the client to prevent shoulder adduction. 3. Encourage the client to move the affected side. Rationale: Placing a small pillow under the shoulder will prevent the shoulder from adducting toward the chest and developing a contracture. The client should not ignore the paralyzed side, and the nurse must encourage the client to move it as much as possible; a written schedule may assist the client in exercising.

The unlicensed assistive personnel (UAP) is caring for the client diagnosed with chronic venous insufficiency. Which action would warrant immediate intervention from the nurse? 1. Removing compression stockings before assisting the client to bed. 2. Taking the client's blood pressure manually after using the machine. 3. Assisting the client by opening the milk carton on the lunch tray. 4. Calculating the client's shift intake and output with a pen and paper.

1. Removing compression stockings before assisting the client to bed. Rationale: Research shows that removing the compression stockings while the client is in bed promotes perfusion of the subcutaneous tissue. The foot of the bed should be elevated

Which assessment data would warrant immediate intervention by the nurse? 1. The client diagnosed with DVT who complains of pain on inspiration. 2. The immobile client who has refused to turn for the last three (3) hours. 3. The client who had an open cholecystectomy who refuses to breathe deeply. 4. The client who has had an inguinal hernia repair who must void before discharge.

1. The client diagnosed with DVT who complains of pain on inspiration. Rationale: A potentially life-threatening complication of DVT is a pulmonary embolus, which causes chest pain. The nurse should determine if the client has "thrown" a pulmonary embolus.

The nurse is caring for clients on a surgical floor. Which client should be assessed first? 1. The client who is four (4) days postoperative abdominal surgery and is complaining of left calf pain when ambulating. 2. The client who is one (1) day postoperative hernia repair who has just been able to void 550 mL of clear amber urine. 3. The client who is five (5) days postoperative open cholecystectomy who has a T-tube and is being discharged. 4. The client who is 16 hours post-abdominal hysterectomy and is complaining of abdominal pain and is expelling flatus.

1. The client who is four (4) days postoperative abdominal surgery and is complaining of left calf pain when ambulating. Rationale: A complication of immobility after surgery is developing a DVT. This client with left calf pain should be assessed for a DVT.

The nurse is teaching the client diagnosed with arterial occlusive disease. Which interventions should the nurse include in the teaching? Select all that apply. 1. Wash legs and feet daily in warm water. 2. Apply moisturizing cream to feet. 3. Buy shoes in the morning hours only. 4. Do not wear any type of knee stocking. 5. Wear clean white cotton socks.

1. Wash legs and feet daily in warm water. 2. Apply moisturizing cream to feet. 4. Do not wear any type of knee stocking. 5. Wear clean white cotton socks. Rationale: 1. Cold water causes vasoconstriction and hot water may burn the client's feet; therefore, warm (tepid) water should be recommended. 2. Moisturizing prevents drying of the feet. 3. Shoes should be purchased in the afternoon when the feet are the largest. 4. This will further decrease circulation to the legs. 5. Colored socks have dye, and dirty socks may cause foot irritation that may lead to breaks in the skin.

The client is diagnosed with expressive aphasia. Which psychosocial client problem would the nurse include in the plan of care? 1. Potential for injury. 2. Powerlessness. 3. Disturbed thought processes. 4. Sexual dysfunction.

2. Powerlessness. Rationale: Expressive aphasia means that the client cannot communicate thoughts but understands what is being communicated; this leads to frustration, anger, depression, and the inability to verbalize needs, which, in turn, causes the client to have a lack of control and feel powerless.

Which assessment data would indicate to the nurse that the client would be at risk for a hemorrhagic stroke? 1. A blood glucose level of 480 mg/dL. 2. A right-sided carotid bruit. 3. A blood pressure (BP) of 220/120 mm Hg. 4. The presence of bronchogenic carcinoma.

3. A blood pressure (BP) of 220/120 mm Hg. Rationale: Uncontrolled hypertension is a risk factor for hemorrhagic stroke, which is a ruptured blood vessel inside the cranium.

Which medication should the nurse expect the health-care provider to order for a client diagnosed with arterial occlusive disease? 1. An anticoagulant medication. 2. An antihypertensive medication. 3. An antiplatelet medication. 4. A muscle relaxant.

3. An antiplatelet medication. Rationale: Antiplatelet medications, such as aspirin or clopidogrel (Plavix), inhibit platelet aggregations in the arterial blood.

The nurse is discharging a client diagnosed with DVT from the hospital on Warfarin. Which discharge instructions should be provided to the client? 1. Have the PTT levels checked weekly until therapeutic range is achieved. 2. Staying at home is best, but if traveling, airplanes are better than automobiles. 3. Avoid green, leafy vegetables and notify the HCP of red or brown urine. 4. Wear knee stockings with an elastic band around the top.

3. Avoid green, leafy vegetables and notify the HCP of red or brown urine. Rationale: Green, leafy vegetables contain vitamin K, which is the antidote for warfarin. These foods will interfere with the action of warfarin. Red or brown urine may indicate bleeding.

The client receiving low molecular weight heparin (LMWH) subcutaneously to prevent DVT following hip replacement surgery complains to the nurse that there are small purple hemorrhagic areas on the upper abdomen. Which action should the nurse implement? 1. Notify the HCP immediately. 2. Check the client's PTT level. 3. Explain this results from the medication. 4. Assess the client's vital signs.

3. Explain this results from the medication Rationale: This is not hemorrhaging, and the client should be reassured that this is a side effect of the medication.

Which instruction should the nurse include when providing discharge instructions to a client diagnosed with peripheral arterial disease? 1. Encourage the client to use a heating pad on the lower extremities. 2. Demonstrate to the client the correct way to apply elastic support hose. 3. Instruct the client to walk daily for at least 30 minutes. 4. Tell the client to check both feet for red areas at least once a week.

3. Instruct the client to walk daily for at least 30 minutes. Rationale: Walking promotes the development of collateral circulation to ischemic tissue and slows the process of atherosclerosis.

Which assessment data would cause the nurse to suspect the client has atherosclerosis? 1. Change in bowel movements. 2. Complaints of a headache. 3. Intermittent claudication. 4. Venous stasis ulcers.

3. Intermittent claudication. Rationale: Intermittent claudication is a sign of generalized atherosclerosis and is a marker of atherosclerosis.

The client is being admitted with Coumadin (warfarin, an anticoagulant) toxicity. Which laboratory data should the nurse monitor? 1. Blood urea nitrogen (BUN) levels. 2. Bilirubin levels. 3. International normalized ratio (INR). 4. Partial thromboplastin time (PTT).

3. International normalized ratio (INR). Rationale: PT/INR is a test to monitor warfarin (Coumadin) action in the body.

A 78-year-old client is admitted to the emergency department (ED) with numbness and weakness of the left arm and slurred speech. Which nursing intervention is priority? 1. Prepare to administer recombinant tissue plasminogen activator (rt-PA). 2. Discuss the precipitating factors that caused the symptoms. 3. Schedule for a STAT computed tomography (CT) scan of the head. 4. Notify the speech pathologist for an emergency consult.

3. Schedule for a STAT computed tomography (CT) scan of the head. Rationale: A CT scan will determine if the client is having a stroke or has a brain tumor or another neurological disorder. If a CVA is diagnosed, the CT scan can determine if it is a hemorrhagic or an ischemic accident and guide treatment. The client must have a documented diagnosis before treatment is started.

The nurse and an unlicensed assistive personnel (UAP) are caring for a client with right-sided paralysis. Which action by the UAP requires the nurse to intervene? 1. The assistant places a gait belt around the client's waist prior to ambulating. 2. The assistant places the client on the back with the client's head to the side. 3. The assistant places a hand under the client's right axilla to move up in bed. 4. The assistant praises the client for attempting to perform ADLs independently.

3. The assistant places a hand under the client's right axilla to move up in bed. Rationale: This action is inappropriate and would require intervention by the nurse because pulling on a flaccid shoulder joint could cause shoulder dislocation; the client should be pulled up by placing the arm underneath the back or using a lift sheet.

Which assessment data would warrant immediate intervention in the client diagnosed with arterial occlusive disease? 1. The client has 2+ pedal pulses. 2. The client is able to move the toes. 3. The client has numbness and tingling. 4. The client's feet are red when standing.

3. The client has numbness and tingling. Rationale: Numbness and tingling are paresthesia, which is a sign of a severely decreased blood supply to the lower extremities.

The home health nurse is admitting a client diagnosed with a DVT. Which action by the client warrants immediate intervention by the nurse? 1. The client takes a stool softener every day at dinnertime. 2. The client is wearing a Medic Alert bracelet. 3. The client takes vitamin E over-the-counter medication. 4. The client has purchased a new recliner that will elevate the legs.

3. The client takes vitamin E over-the-counter medication. Rationale: Vitamin E can affect the action of warfarin. The nurse should explain to the client that these and other medications could potentiate the action of warfarin.

The nurse is teaching a class on venous insufficiency. The nurse would identify which condition as the most serious complication of chronic venous insufficiency? 1. Arterial thrombosis. 2. Deep vein thrombosis. 3. Venous ulcerations. 4. Varicose veins.

3. Venous ulcerations. Rationale: Venous ulcerations are the most serious complication of chronic venous insufficiency. It is very difficult for these ulcerations to heal, and often clients must be seen in wound care clinics for treatment.

Which assessment data would the nurse expect to find in the client diagnosed with chronic venous insufficiency? 1. Decreased pedal pulses. 2. Cool skin temperature. 3. Intermittent claudication. 4. Brown discolored skin.

4. Brown discolored skin. Rationale: Chronic venous insufficiency leads to chronic edema that, in turn, causes a brownish pigmentation to the skin.

The 85-year-old client diagnosed with a stroke is complaining of a severe headache. Which intervention should the nurse implement first? 1. Administer a nonnarcotic analgesic. 2. Prepare for STAT magnetic resonance imaging (MRI). 3. Start an intravenous infusion with D5W at 100 mL/hr. 4. Complete a neurological assessment.

4. Complete a neurological assessment. Rationale: The nurse must complete a neurological assessment to help determine the cause of the headache before taking any further action.

The client has been diagnosed with a cerebrovascular accident (stroke). The client's wife is concerned about her husband's generalized weakness. Which home modification should the nurse suggest to the wife prior to discharge? 1. Obtain a rubber mat to place under the dinner plate. 2. Purchase a long-handled bath sponge for showering. 3. Purchase clothes with Velcro closure devices. 4. Obtain a raised toilet seat for the client's bathroom.

4. Obtain a raised toilet seat for the client's bathroom. Rationale: Raising the toilet seat is modifying the home and addresses the client's weakness in being able to sit down and get up without straining muscles or requiring lifting assistance from the wife.

The nurse is planning care for a client experiencing agnosia secondary to a cerebrovascular accident. Which collaborative intervention will be included in the plan of care? 1. Observe the client swallowing for possible aspiration. 2. Position the client in a semi-Fowler's position when sleeping. 3. Place a suction setup at the client's bedside during meals. 4. Refer the client to an occupational therapist for evaluation.

4. Refer the client to an occupational therapist for evaluation. Rationale: A collaborative intervention is an intervention in which another health-care discipline—in this case, occupational therapy—is used in the care of the client.

The client diagnosed with peripheral vascular disease is overweight, has smoked two (2) packs of cigarettes a day for 20 years, and sits behind a desk all day. What is the strongest factor in the development of atherosclerotic lesions? 1. Being overweight. 2. Sedentary lifestyle. 3. High-fat, high-cholesterol diet. 4. Smoking cigarettes.

4. Smoking cigarettes Rationale: Tobacco use is the strongest factor in the development of atherosclerotic lesions. Nicotine decreases blood flow to the extremities and increases heart rate and blood pressure. It also increases the risk of clot formation by increasing the aggregation of platelets.

The client is employed in a job that requires extensive standing. Which intervention should the nurse include when discussing how to prevent varicose veins? 1. Wear low-heeled, comfortable shoes. 2. Wear clean white cotton socks. 3. Move the legs back and forth often. 4. Wear graduated compression hose.

4. Wear graduated compression hose. Rationale: Graduated compression hose help decrease edema and increase the circulation back to the heart; this helps prevent varicose veins. Options "1" and "2" could be eliminated as possible answers if the test taker knows that the varicose veins are in the leg, because options "1" and "2" are addressing the feet.

While teaching a wellness class on the warning signs of stroke, a participant asks the nurse, "What's the most important thing for me to remember?" What is an appropriate response by the nurse? A) "Be alert for sudden weakness or numbness." B) "Know your family history." C) "Keep a list of your medications." D) "Call 911 if you notice a gradual onset of paralysis or confusion."

A) "Be alert for sudden weakness or numbness." Rationale: Warning signs of stroke include sudden weakness, numbness, paralysis, loss of speech, confusion, dizziness, unsteadiness, and loss of balance-the key word is sudden. Family history and past medical history can be indicators for risk, but they are not warning signs of stroke. Gradual onset of symptoms is not indicative of a stroke.

The nurse is providing discharge instructions to a postpartum client recovering from deep venous thrombosis. What should these instructions include? Select all that apply. A) Avoid crossing the legs. B) Avoid long car trips. C) Avoid prolonged standing or sitting. D) Take frequent walks. E) Take a daily aspirin dose of 650 mg.

A) Avoid crossing the legs. C) Avoid prolonged standing or sitting. D) Take frequent walks. Rationale: The client should be instructed to avoid crossing the legs because it increases pressure on the veins of the lower extremities. The client should be instructed also to avoid prolonged standing or sitting, which contributes to venous stasis. The client should also be instructed to take frequent walks to promote venous return. The client should not be instructed to take a daily aspirin, because it will increase anticoagulant activity and could interact with other medication prescribed for the treatment of the deep venous thrombosis. The client does not need to be instructed to avoid long car trips but rather to take frequent breaks during long car trips.

The nurse is planning care for a client admitted with a stroke. Which intervention would support the client's sensorimotor needs? A) Encourage use of non-affected arm to feed self, bathe, and dress. B) Speak in normal conversational pattern and tones. C) Provide complete care. D) Talk loudly and distinctly.

A) Encourage use of non-affected arm to feed self, bathe, and dress. Rationale: To address the client's alteration in sensory and motor statuses, the nurse should encourage the client to use the non-affected arm to feed self, bathe, and dress. The nurse should not provide all care for the client. The nurse should not talk loudly to the client but should articulate slower and face the client when speaking. Speaking in normal conversational patterns and tones may not be adequate when communicating with the client.

A client diagnosed with peripheral vascular disease is obese, has a 30-year history of cigarette smoking, and works as a contractor. What should the nurse instruct the client about the diagnosis? A) Nicotine is a vasoconstrictor. B) Obesity is a factor in cardiovascular disease but not peripheral vascular disease. C) Nicotine primarily affects coronary arteries and the lungs. D) The client's occupation is a major risk factor.

A) Nicotine is a vasoconstrictor. Rationale: The vasoconstrictive properties of nicotine will worsen the client's peripheral vascular disease (PVD) by further decreasing peripheral blood flow. One of the most important parts of treatment is the cessation of cigarette smoking. The client's occupation is not a risk factor related to PVD. Obesity is a risk factor for both cardiovascular as well as PVD; however, the nurse should focus on smoking cessation as a first priority with this client.

While completing a health history with an older client, the nurse learns that the client experienced a transient ischemic attack several months ago. What does this information suggest to the nurse? A) The client is at risk for an ischemic thrombotic stroke. B) The client will have minimal symptoms should a stroke occur. C) The client will not experience a stroke in the future. D) The client is at high risk for a hemorrhagic stroke.

A) The client is at risk for an ischemic thrombotic stroke. Rationale: Transient ischemic attacks are often warning signs of an ischemic thrombotic stroke. One or many transient ischemic attacks may precede a stroke, with the time between the attack and the stroke ranging from hours to months. A hemorrhagic stroke is caused by the rupture of a cerebral blood vessel and is not related to a transient ischemic attack. There is no way to predict the symptoms the client will experience after a stroke.

An older client is diagnosed with a left cerebral hemorrhage. To meet the needs of the client and family, the nurse will provide teaching in which areas? Select all that apply. A) Time adjustment to complete activities B) How to use a sign board C) Nutrition support D) Transfer techniques E) Information about impulse control

A) Time adjustment to complete activities B) How to use a sign board D) Transfer techniques Rationale: The left cerebral hemisphere is responsible for the language center, calculation skills, and thinking/reasoning abilities. Reading and speaking could be compromised if there is left-sided brain damage. The client also might display over-cautious behavior and might be slow to respond or complete activities. Transfer techniques would apply regardless of the side involved. Impulse control problems can arise with right-sided involvement. Nutritional support may or may not be an issue with this client.

A client who is diagnosed with stroke is very drowsy but can respond when awakened. Using the National Institutes of Health Stroke​ Scale, which level of consciousness should the nurse​ document? A. 1 B. 0 C. 3 D. 2

A. 1 ​Rationale: A score of 1 means that the client is not alert but is arousable by minor stimulation to​ obey, answer, or respond. A score of 0 means that the client is alert and keenly responsive. A score of 2 means that the client is not​ alert, requires repeated stimulation to​ attend, or is obtunded and requires strong or painful stimuli to make movements. A score of 3 means that the client responds only with motor or autonomic effects or is totally​ unresponsive, flaccid, and areflexic.

The nurse is planning care for a client with a deep venous thrombosis of the right calf. Which should the nurse include in this​ client's plan of​ care? (Select all that​ apply.) A. Applying​ warm, moist heat to the affected area every 6 hours B. Measuring the calf and thigh diameter of the right leg every shift C. Encouraging​ range-of-motion exercises every 2-4 hours D. Coaching to perform deep breathing and coughing every 2 hours E. Assisting to a sitting position with the legs dependent every 4 hours

A. Applying​ warm, moist heat to the affected area every 6 hours B. Measuring the calf and thigh diameter of the right leg every shift C. Encouraging​ range-of-motion exercises every 2-4 hours D. Coaching to perform deep breathing and coughing every 2 hours ​Rationale: Interventions that may be appropriate for inclusion in the plan of care for the client with DVT include measuring the calf and thigh diameter of the affected leg every​ shift; applying​ warm, moist heat to the affected extremity at least 4 times a​ day; encouraging​ range-of-motion exercises; and assisting with deep breathing and coughing. The legs should be​ elevated, not dependent.

The nurse is caring for a postoperative client who has limited mobility. Which assessment finding should the nurse report as a possible sign of a deep venous thrombosis​ (DVT)? (Select all that​ apply.) A. Area of redness along a left lower leg vein B. Muscle twitching of the left thigh C. Aching of the left calf D. Pale skin color of the left lower leg E. Swelling of the left lower leg

A. Area of redness along a left lower leg vein C. Aching of the left calf D. Pale skin color of the left lower leg E. Swelling of the left lower leg ​Rationale: Manifestations of DVT include calf​ pain/tightness or​ dull, aching pain in the affected extremity that gets worse with​ walking; possible​ tenderness, swelling,​ warmth, and erythema along the affected​ vein; and edema and cyanosis of the affected extremity. Muscle twitching is not a manifestation of DVT.

The nurse is evaluating a client who​ states, "I usually walk 30 minutes every​ morning, but lately my leg cramps and hurts after just a few minutes. The pain goes away after I stop​ walking, though." Which action should the nurse do first​? A. Assess the posterior tibial and pedal pulses. B. Ask the client about skin color changes. C. Notify the healthcare provider. D. Discuss benefits of daily exercise

A. Assess the posterior tibial and pedal pulses. Rationale: This client is describing symptoms of intermittent claudication. The nurse should assess the strength and equality of peripheral pulses to determine perfusion. Changes in skin color are important but not the priority. The nurse should complete the assessment before contacting the healthcare provider or discussing the benefits of daily exercise.

A client presents with​ tenderness, edema, and erythema of a lower extremity. Which diagnostic test should the nurse anticipate being ordered for this​ client? (Select all that​ apply.) A. Duplex venous ultrasonography B. Magnetic resonance angiography C. Color-flow Doppler ultrasound D. Magnetic resonance imaging E. Plethysmography

A. Duplex venous ultrasonography D. Magnetic resonance imaging E. Plethysmography ​Rationale: Duplex venous​ ultrasonography, magnetic resonance​ imaging, and plethysmography are used to diagnose a deep venous thrombosis.​ Color-flow Doppler ultrasound and magnetic resonance angiography are used to diagnose peripheral vascular disease.

The nurse is caring for a client admitted with new onset atrial fibrillation. Which intervention should be included in the plan of​ care? (Select all that​ apply.) A. Elevate the foot of the bed with knees slightly flexed. B. Monitor for bilateral edema. C. Assess extremities for cyanosis. D. Monitor for tenderness and warmth of bilateral lower extremities. E. Teach the client to report​ sharp, stabbing pain in calf.

A. Elevate the foot of the bed with knees slightly flexed. B. Monitor for bilateral edema. C. Assess extremities for cyanosis. D. Monitor for tenderness and warmth of bilateral lower extremities Rationale: Atrial fibrillation is a risk factor for deep venous thrombosis​ (DVT). Elevating the feet and keeping the knees slightly flexed will prevent venous stasis and decrease the risk for DVT.​ Edema, aching​ pain, warmth,​ cyanosis, and​ tenderness, especially in one lower​ extremity, are signs of DVT.

A​ client's daughter asks how to prevent peripheral vascular disease. Which information should the nurse include as a preventative​ measure? (Select all that​ apply.) A. Exercising regularly B. Quitting smoking C. Starting blood pressure medications D. Maintaining a healthy weight E.Starting​ cholesterol-lowering medications

A. Exercising regularly B. Quitting smoking D. Maintaining a healthy weight Rationale: Preventative measures for PVD include maintaining a healthy lifestyle​ (ideal weight,​ exercising), smoking​ cessation, and following treatment for chronic illnesses. It is outside of the scope of the nurse to prescribe blood pressure or​ cholesterol-lowering medications. It is also unknown whether this client requires those medications.​ However, blood pressure and​ cholesterol-lowering medications can help slow or reverse the progress of PVD if taken as ordered by a provider.

The nurse is preparing to administer an initial dose of heparin. Which should be included in the​ client's plan of​ care? A. Give a test dose if the client has a history of asthma. B. Assess INR levels daily to ensure therapeutic range is maintained. C. Administer in conjunction with aspirin therapy. D. Keep vitamin K available to reverse the effects of the heparin in case excessive bleeding occurs.

A. Give a test dose if the client has a history of asthma ​Rationale: Clients with a history of multiple allergies or asthma should be given a test dose of heparin. It is not appropriate to administer heparin in conjunction with aspirin. INR levels are checked for warfarin. Vitamin K reverses the effects of warfarin.

The nurse is caring for a client with peripheral vascular disease​ (PVD). Which nursing intervention should the nurse​ implement? (Select all that​ apply.) A. Keep lower extremities warm. B. Encourage frequent position change. C. Encourage exercise. D. Keep legs in dependent position during sleep. E. Assess peripheral pulses.

A. Keep lower extremities warm. B. Encourage frequent position change. C. Encourage exercise. E. Assess peripheral pulses. ​Rationale: To evaluate and promote tissue perfusion in the client with​ PVD, the nurse should assess peripheral pulses to ensure adequate​ perfusion, keep lower extremities warm to prevent vasoconstriction associated with cold​ temperatures, encourage exercise to increase circulation to lower​ extremities, and encourage frequent position changes to avoid a decrease in circulation to the lower extremities. The nurse should elevate the legs during sleep and rest. Elevation promotes venous return from the​ extremity, increasing circulation and relieving pain.

The nurse is reviewing the personal and medical history of several clients. Which finding indicates that a client is at risk for the development of a deep venous​ thrombosis? (Select all that​ apply.) A. Lung cancer B. Diabetes mellitus C. 28​ weeks' gestation D. Hormone therapy E. Hypercholesterolemia

A. Lung cancer C. 28​ weeks' gestation D. Hormone therapy Rationale: Hormone​ therapy, lung​ cancer, and pregnancy are all risk factors for the development of DVT. Hypercholesterolemia and diabetes mellitus are risk factors for peripheral vascular​ disease, not DVT.

A client diagnosed with a stroke is having difficulty walking and may require the use of a walker. Which area should the nurse make a referral​ to? A. Occupational therapy B. Physical therapy C. Home health D. Speech and language therapy

A. Occupational therapy ​Rationale: Occupational therapy can help a client learn to use assistive devices and create a plan for regaining motor skills. Physical therapy helps increase physical strength and coordination and prevent contractures. Speech and language therapy improve communication and swallowing. Home health may be​ needed, but the priority is learning to use the assistive device.

The nurse is performing a nursing assessment for a client with peripheral vascular disease​ (PVD). Which data should the nurse collect during the health​ history? (Select all that​ apply.) A. Presence of pain B. History of coronary artery disease C. Current diet D. Current medications E. Presence of skin discoloration

A. Presence of pain B. History of coronary artery disease C. Current diet D. Current medications Rationale: During the health history portion of the nursing assessment for the client with​ PVD, the nurse will assess client history of coronary artery disease​ (CAD), current medications and​ diet, and any complaints of pain. Presence of skin discoloration would be assessed during the physical exam portion of the nursing assessment.

The nurse is caring for a client recently diagnosed with peripheral vascular disease​ (PVD). Which intervention should the nurse teach the​ client? (Select all that​ apply.) A. Put on​ above-the-knee elastic hose with the legs elevated. B. Encourage wearing​ knee-high compression stockings. C. Avoid walking or standing to allow the legs to rest. D. Elevate the legs when asleep or resting. E. Avoid crossing the legs when in a sitting position.

A. Put on​ above-the-knee elastic hose with the legs elevated. D. Elevate the legs when asleep or resting. E. Avoid crossing the legs when in a sitting position. Rationale: Nursing interventions for PVD include elevating the legs when resting or​ asleep, avoiding crossing the legs or putting pressure on the back of the​ knees, and putting on hose after the legs have been elevated. The client should be encouraged to walk as much as possible. Compression hose should be above the knee and tighter over the feet than the top of the leg.

The nurse is completing a physical assessment on a client with edema and pooling of blood in the veins of the lower extremities. The nurse suspects the diagnosis of chronic venous insufficiency. Which additional assessment finding should the nurse expect to​ observe? A. Skin hyperpigmentation B. Cool feet and toes C. Absent pedal pulses D. Gangrene

A. Skin hyperpigmentation Rationale: Symptoms of chronic venous insufficiency include edema of the lower extremities and hyperpigmentation of the skin of the feet and ankles. Absent​ pulses, cool skin on the feet and​ toes, and gangrene are signs of an arterial​ problem, not a venous problem.

The nurse is evaluating the goal established for a client with peripheral vascular​ disease, "The client will learn appropriate foot and wound​ care." Which outcome demonstrates goal​ achievement? A. The client demonstrates proper wound care techniques to the nurse. B. The client informs the nurse that the wound is improving C. The​ client's leg wound shows no signs of infection. D. The​ client's leg ulcer is showing signs of healing.

A. The client demonstrates proper wound care techniques to the nurse. ​Rationale: Client goals are​ measurable, specific,​ realistic, and achievable. The client verbalizing proper wound care demonstrates goal achievement. The ulcer showing signs of healing and​ improvement, and no signs of infection are medical outcomes.

A nurse is examining a client diagnosed with peripheral vascular disease​ (PVD) who has an ulcer on the great right toe. Which additional assessment finding should the nurse​ expect? (Select all that​ apply). A. The toenails are thickened. B. There is an absence of hair on the legs. C. The extremity is cool to touch. D. There is brown pigmentation of the lower extremity. E. There is pitting edema in the lower extremity.

A. The toenails are thickened. B. There is an absence of hair on the legs. C. The extremity is cool to touch. ​Rationale: Wounds on the​ toes, absence of hair on the​ legs, cool​ extremities, and thick toenails are all features of arterial problems. Venous problems are characterized by brown pigmentation of the skin of the lower extremity and edema.

While conducting an​ assessment, the nurse concludes that a client is at risk for developing a deep venous thrombosis. Which assessment finding led the nurse to this​ conclusion? (Select all that​ apply.) A. Treatment for bladder cancer B. A myocardial infarction 2 years ago C. A history of atrial fibrillation D. Controlling type 2 diabetes mellitus with diet and exercise E. Taking​ over-the-counter medication for arthritis

A. Treatment for bladder cancer B. A myocardial infarction 2 years ago C. A history of atrial fibrillation ​Rationale: Risk factors for the development of a DVT include​ cancer, atrial​ fibrillation, and myocardial infarction. Use of​ over-the-counter medication for arthritis and having controlled type 2 diabetes mellitus are not risk factors for the development of this health problem.

The nurse is teaching a client with atrial fibrillation about deep venous thrombosis prevention. Which should the nurse instruct the client to avoid​? ​(Select all that​ apply.) A. ​Tight-fitting clothing B. Prolonged standing C. Crossing the legs D. Extreme exercise E. Prolonged sitting

A. ​Tight-fitting clothing B. Prolonged standing C. Crossing the legs E. Prolonged sitting Rationale: Actions to prevent development of a deep venous thrombosis​ (DVT) include avoiding prolonged standing or​ sitting, avoiding crossing the​ legs, and avoiding​ tight-fitting or binding garments and stockings. Avoiding extreme exercise does not prevent development of a DVT.

A client receiving heparin therapy for deep venous thrombosis complains of severe chest pain and shortness of breath. Suspecting a pulmonary embolism, what action should the nurse perform first? A) Assess pulse, respirations, and blood pressure. B) Apply oxygen and elevate the head of the bed. C) Reassure the client and notify family members. D) Increase the rate of heparin infusion.

B) Apply oxygen and elevate the head of the bed. Rationale: Applying oxygen and elevating the head of the bed will promote ventilation and gas exchange in those alveoli that are well perfused, helping to maintain tissue oxygenation. Increasing the rate of heparin infusion cannot be done by the nurse without an order from a healthcare provider. Reassuring the client and notifying family members are not priorities, although these measures can decrease the client's anxiety; the priority is to begin oxygen therapy and elevate the head of the bed to increase oxygenation to the tissues. Assessing pulse, respiration, and blood pressure will be performed following the initiation of oxygen therapy and bed elevation.

A nurse is caring for a client with venous stasis whose lower extremities have a brown pigmentation appearance. Which is this pigmentation appearance best attributed to? A) The necrosis of subcutaneous fat due to tissue hypoxia B) Breakdown of red blood cells in the congested tissues C) The inflammatory and immune response from congested circulation D) Skin atrophy caused by lack of circulation

B) Breakdown of red blood cells in the congested tissues Rationale: Breakdown of red blood cells in the congested tissues causes brown skin pigmentation. While the other choices may occur with PVD, they are not responsible for the cause of brown pigmentation to the skin.

A client is admitted to the hospital in order to have surgical intervention due to peripheral vascular disease (PVD). Which procedure is the likely intervention? A) Stent placement B) Endarterectomy C) Percutaneous transluminal angioplasty D) Atherectomy

B) Endarterectomy Rationale: Surgical intervention for PVD includes endarterectomy and bypass grafts. All other choices are non-surgical interventions for PVD.

A client with peripheral vascular disease is experiencing pain. What can the nurse do to assist this client? A) Elevate legs in bed with pillows under the knees. B) Keep the extremities warm with blankets. C) Encourage to ambulate and stand on legs 4 times each day. D) Apply cool compresses to the extremities.

B) Keep the extremities warm with blankets. Rationale: The nurse should help keep the client's extremities warm with blankets, as heat promotes vasodilation and reduces pain. Cool compresses will constrict vessels and cause more pain. Encouraging the client to ambulate and stand on the legs 4 times each day may be too aggressive. Pillows should not be placed under the knees.

The nurse is planning care for a client with peripheral vascular disease who is at risk for Impaired Skin Integrity. What would be included in this client's plan of care? A) Restrict fluids. B) Keep the skin clean and dry, and moisturize areas of dryness. C) Encourage bed rest with legs elevated on pillows. D) Consult a dietitian for low-protein diet.

B) Keep the skin clean and dry, and moisturize areas of dryness. Rationale: The client with peripheral vascular disease who is at risk for impaired skin integrity should have meticulous skin care to keep the skin clean, dry, and well-moisturized to prevent skin breakdown. A low-protein diet is not beneficial for wound healing and may not be indicated for this client. A fluid restriction would dry tissues and not promote good skin turgor. Bed rest with legs elevated on pillows could increase the client's pain and would not help with preventing skin breakdown.

A client being treated for a deep venous thrombosis is experiencing pain. What can the nurse do to assist this client? Select all that apply. A) Apply an egg-crate mattress on the bed. B) Maintain bed rest as ordered. C) Apply warm moist heat to the area four times a day. D) Encourage position changes every 2 hours. E) Measure calf and thigh diameter daily.

B) Maintain bed rest as ordered. C) Apply warm moist heat to the area four times a day. E) Measure calf and thigh diameter daily. Rationale: Interventions to address pain include applying warm moist heat to the area four times a day, maintaining bed rest as ordered, and measuring calf and thigh diameter daily. Applying an egg-crate mattress on the bed and encouraging position changes every 2 hours would be appropriate for the client experiencing Ineffective Tissue Perfusion.

The nurse is evaluating teaching provided to a client with peripheral vascular disease. Which client observation indicates teaching has been effective? A) Sitting in a chair with a pillow behind knees B) Washing the lower extremities with mild soap, drying the legs, and applying a light moisturizer C) Sitting in a chair with left leg crossed over the right D) Smoking a pipe instead of cigarettes

B) Washing the lower extremities with mild soap, drying the legs, and applying a light moisturizer Rationale: The client who is observed washing the legs with mild soap, drying the legs, and applying a moisturizer is putting into practice the instruction regarding peripheral vascular disease. Sitting in a chair with legs crossed or with a pillow behind the knees would indicate further instruction was needed. The client smoking a pipe instead of cigarettes needs additional instruction regarding the hazards of tobacco.

The nurse is planning care for an older client with chronic venous insufficiency. What should the nurse plan to teach this client? A) Keep the legs dependent as much as possible and elevate only when asleep. B) Wear elastic hose as prescribed. C) Standing will prevent the progression of the disease. D) Cross legs only at the knees.

B) Wear elastic hose as prescribed. Rationale: Care and treatment of a client with peripheral vascular disease includes instruction. The nurse should instruct the client to wear elastic hose as prescribed. The nurse should instruct the client to avoid sitting or standing for long periods of time. The legs should be elevated during rest and when asleep. Crossing the legs should be avoided.

A client admitted with chronic venous insufficiency has an infected wound of the left lower extremity. What will the nurse find when assessing this wound? Select all that apply. A) Pulses absent in the extremity with the wound B) Wound that is pink with skin warm C) Ulceration that is pale in color D) Skin surrounding ulcer that is cool to the touch E) Surrounding skin brown in color

B) Wound that is pink with skin warm E) Surrounding skin brown in color Rationale: Manifestations of a venous status ulcer would be a pink wound with warm skin and areas of hyperpigmentation. An ulcer that is pale in color with cool skin temperature and absent pulses is manifestations of arterial ulcers.

The nurse is caring for a client diagnosed with a deep venous thrombosis. Which client statement requires an​ intervention? A. "I will reposition myself​ frequently." B. "I should wash my leg in an​ alcohol-based solution​ daily." C. "I will keep my legs elevated with my knees​ flexed." D. ​"I should increase my fluid​ intake."

B. "I should wash my leg in an​ alcohol-based solution​ daily." Rationale: Mild soaps and lotions should be used to clean the affected leg and foot daily. Alcohol can cause the skin to dry and​ crack, increasing the risk for infection. Increased fluid and dietary fiber intake should be encouraged because constipation is a common complication of immobility. Frequent position changes while awake will reduce skin breakdown. Elevation of the extremities promotes venous return and reduces peripheral edema. Knee flexion promotes muscle relaxation.

A nurse is teaching a client diagnosed with peripheral arterial disease about proper positioning of the lower extremities. Which client statement indicates a need for further​ teaching? A. "I can sit in a chair while I watch​ television." B. "I will elevate my legs and feet on pillows when I lie​ down." C. "I should hang my legs off the bed while I am​ resting." D. "I will avoid crossing my​ legs."

B. "I will elevate my legs and feet on pillows when I lie​ down." Rationale: Elevation of the affected limb can slow arterial blood flow to the​ feet, so this position should be avoided. The client may sleep with the extremities hanging or positioned upright in a chair. The client is also instructed to avoid crossing the legs because this interferes with blood flow. Next Question

A nurse is teaching a client with suspected peripheral vascular disease​ (PVD) about segmental pressure measurements. Which statement should the nurse include in the​ teaching? A. "If you have​ PVD, the BP in your legs will drop further during​ exercise." B. "If you have​ PVD, your BP may be lower in your legs than your​ arms." C. "We need to do this before surgery to locate and evaluate the blood​ clot." D. "This uses sound waves reflected off red blood cells to look at blood​ flow."

B. "If you have​ PVD, your BP may be lower in your legs than your​ arms." Rationale: Segmental pressure measurements use a Doppler and sphygmomanometer to compare BPs in the upper and lower extremities. In​ PVD, the BP in the legs will be lower than in the arms. A Doppler uses sound waves that reflect off of RBCs to evaluate blood flow. Angiography is done before revascularization surgery to locate and evaluate the extent of the arterial obstruction. A stress test measures pressures in the lower extremities during exercise.

Which description of an acute embolic stroke given by the nurse is most​ accurate? A. Cerebral vascular pressure exceeds the elasticity of the vessel​ wall, resulting in hemorrhages. B. A blood clot lodges in a cerebral vessel and blocks blood flow. C. Infarcted areas in the brain slough​ off, leaving cavities in the brain tissue. D. The local cerebral tissue becomes engorged with blood from a ruptured cerebral vessel.

B. A blood clot lodges in a cerebral vessel and blocks blood flow. Rationale: In embolic​ stroke, a blood clot or other matter traveling through cerebral blood vessels becomes lodged in a narrow vessel blocking blood flow. The area of the brain supplied by the blocked vessel becomes ischemic. The clot may originate from a thrombus formed in the left side of the heart during atrial​ fibrillation, bacterial​ endocarditis, recent myocardial infarction​ (MI), atherosclerotic plaque from the carotid​ artery, rheumatic heart​ disease, or ventricular aneurysm. Infarcted areas of the brain become ischemic but do not slough off. Hemorrhagic stroke is when local cerebral tissue becomes engorged with blood from a ruptured cerebral vessel. An embolic stroke is not the result of cerebral vascular pressure increases.

The nurse is giving a presentation regarding the pathologic factors that may lead to the formation of a thrombus. Which participant statement indicates a need for further​ teaching? A. "Circulatory stasis can lead to the formation of a​ thrombus." B. An active lifestyle can lead to the formation of a​ thrombus." C. "Hypercoagulability is a pathologic factor associated with a​ thrombus." D. "Vascular damage is a pathologic factor associated with a​ thrombus."

B. An active lifestyle can lead to the formation of a​ thrombus." ​Rationale: Virchow's triad is named for the three pathologic factors associated with the formation of a​ thrombus: circulatory​ stasis, vascular​ damage, and hypercoagulability. An inactive lifestyle​ (not an active​ lifestyle) can lead to circulatory stasis and thrombus formation.

The nurse is creating a plan of care for a client diagnosed with a deep venous thrombosis​ (DVT). Which intervention should be included in the care​ plan? A. Apply cold compresses 4 times daily. B. Assess regularly for pain and treat as needed. C. Assess skin at admission and again at discharge. D. Assist the client to ambulate at least twice daily.

B. Assess regularly for pain and treat as needed. Rationale: Pain is common with DVT and should be assessed and treated regularly. Increased pain should be reported to the healthcare provider.​ Warm, moist compresses should be used. Skin should be assessed daily. The client will most likely be on​ bedrest, as increased mobility could cause the thrombus to dislodge and travel to the lungs.

The nurse caring for a client with a history of transient ischemic attacks​ (TIAs) is reviewing medications ordered to prevent a stroke. Which medication therapy requires​ follow-up? A. Anticoagulant B. Beta blocker C. Thiazide diuretic D. Antiplatelet

B. Beta blocker ​Rationale: Even though beta blockers are useful in lowering blood​ pressure, they are very limited in preventing stroke. Anticoagulants and antiplatelets are used to reduce the risk of stroke in clients with TIAs. Hypertension is the leading cause of stroke. Research indicates that thiazide diuretics and certain other antihypertensives are useful in reducing stroke risk.

A client who had a stroke secondary to cerebral stenosis discussed surgical options with the surgeon. Which option should the nurse anticipate will be​ performed? A. Carotid endarterectomy B. Carotid angioplasty with stenting C. Extracranial-intracranial bypass D. Cautious observation only

B. Carotid angioplasty with stenting ​Rationale: Carotid angioplasty with stenting is used to surgically treat cerebral stenosis. Carotid endarterectomy is used to remove plaque from a carotid artery. An extracranial-intracranial bypass may be required if an occluded or stenotic vessel is not directly accessible. The client has already had a stroke from the​ stenosis, and there is no indication that comorbidities could prevent the surgery.

Which nursing diagnosis should be used to guide the care for a client with a deep venous thrombosis​ (DVT)? (Select all that​ apply.) A. Oxygenation, Ineffective B. Comfort, Impaired C. Tissue​ Perfusion, Impaired D. Protection, Ineffective E. Mobility: Physical, Impaired

B. Comfort, Impaired C. Tissue​ Perfusion, Impaired D. Protection, Ineffective E. Mobility: Physical, Impaired

A client was diagnosed with a thrombotic stroke of the vertebral artery. Which assessment does the nurse expect to​ make? A. Global aphasia B. Dysphagia C. Contralateral paralysis D. Stupor

B. Dysphagia Rationale: Dysphagia is the clinical manifestation that is associated with a stroke that affects the vertebral artery. The other clinical manifestations are seen with internal carotid and middle cerebral artery involvement.

The nurse is reviewing interventions aimed at maintaining cerebral perfusion in a client who had a thrombotic stroke. Which intervention should the nurse​ question? A. Monitoring mental status and level of consciousness B. Encouraging active​ range-of-motion exercises C. Monitoring respiratory status D. Placing the client in a​ side-lying position

B. Encouraging active​ range-of-motion exercises Rationale: Active​ range-of-motion exercises promote physical mobility but will not directly assist in maintaining cerebral perfusion. The initial focus of care is to identify changes in​ airway, breathing, and circulation that could indicate decreased cerebral perfusion. Maintaining adequate oxygenation and positioning to facilitate breathing is appropriate.

The nurse is reviewing the plan of care for a client who is unresponsive following a stroke. Which intervention should the nurse​ question? A. Monitoring lower extremities for symptoms of thrombophlebitis B. Encouraging active​ range-of-motion exercises C. Turning the client every 2 hours D. Elevating the head of the bed 30 degrees

B. Encouraging active​ range-of-motion exercises ​Rationale: Each of the nursing implementations listed are appropriate for promoting physical mobility.​ However, the client is unresponsive and therefore cannot complete active​ range-of-motion exercises; they would require passive​ range-of-motion exercises.

A community health nurse is teaching a group of adults about the risk factors associated with peripheral vascular disease​ (PVD) and chronic venous insufficiency​ (CVI). Which risk factor should the nurse​ include? (Select all that​ apply.) A. Male sex B. Excess body weight C. Physical inactivity D. Age 45 or older E. Increased cholesterol levels

B. Excess body weight C. Physical inactivity E. Increased cholesterol levels Rationale: Risk factors associated with PVD and CVI include increased cholesterol​ levels, excess body weight or​ obesity, and physical inactivity. Clients age 50 and older are at greatest risk for developing PVD or CVI. Males and females are equally affected by these conditions.

The nurse is caring for a client recovering from a stroke in the rehabilitation setting. Which is the goal of care during this​ stage? A. Minimizing brain injury B. Improving muscle strength and coordination C. Dispatching rapid emergency medical services​ (EMS) D. Diagnosing the type and cause of stroke

B. Improving muscle strength and coordination Rationale: During the rehabilitation treatment stage of​ stroke, the focus is on client safety and improvement of muscle strength and coordination. Priorities during the treatment stage of acute care immediately following a stroke include rapid EMS​ dispatch, diagnosing the type and cause of​ stroke, and other interventions to minimize brain injury and maximize client recovery.

The nurse is teaching a class about the causes of a hemorrhagic stroke. Which should the nurse​ include? (Select all that​ apply.) A.Damage to the blood-brain barrier B. Rupture of a fragile arterial vessel in the brain C. Traumatic injury to the brain D. Atherosclerotic plaque breaking off in the artery E. Ruptured aneurysm in the brain

B. Rupture of a fragile arterial vessel in the brain C. Traumatic injury to the brain E. Ruptured aneurysm in the brain ​Rationale: Arterial bleeds in the brain cause hemorrhagic stroke. Blood enters the brain and puts pressure on brain tissue. Manifestations occur suddenly because of the rapid rise in intracranial pressure​ (ICP). Aneurysms in the brain enlarge over time. This causes the arterial walls to become thin and subject to rupturing. Falls and other traumatic injuries can cause the arterial walls to rupture. This causes intracranial bleeding with accompanying increased ICP. Stroke caused by traumatic injury has the poorest outcome with greater likelihood of death. Atherosclerotic plaque that breaks off causes obstruction in the vessel lumen. This is ischemic​ stroke, rather than hemorrhagic. Hemorrhagic stroke involves bleeding into the brain. The blood-brain barrier prevents potentially harmful substances from entering the brain. Hemorrhagic stroke is not caused by damage to the blood-brain barrier.​ However, hemorrhagic stroke could cause damage to the blood-brain barrier and therefore allow harmful substances to enter the brain.

The nurse should assess which client for possible deep venous​ thrombosis? (Select all that​ apply.) A. The client with​ sharp, stabbing pain in the right lower extremity only when walking B. The client with bilateral lower extremity edema but slightly greater in the left lower extremity C. The client with cyanosis of the right lower extremity D. The client with capillary refill less than 3 seconds in one lower extremity and 4 seconds in the other E. The client who recently had surgery but has no reports of pain or swelling in the lower extremities

B. The client with bilateral lower extremity edema but slightly greater in the left lower extremity C. The client with cyanosis of the right lower extremity D. The client with capillary refill less than 3 seconds in one lower extremity and 4 seconds in the other E. The client who recently had surgery but has no reports of pain or swelling in the lower extremities Rationale: Signs and symptoms of DVT include​ cyanosis, dull aching pain when​ walking, edema greater in one​ leg, and capillary refill greater in one leg. DVT is often asymptomatic. The client who has had surgery is at risk for DVT and should be assessed.

The nurse taught a group of clients recovering from a stroke how to perform active​ range-of-motion exercises. Which client requires further​ teaching? A. The client performing extension and hyperextension of the neck B. The client with​ right-sided paralysis flexing and extending only the left knee C. The client with​ left-sided paralysis using the right arm to help flex and extend the left wrist D. The client performing​ flexion, extension, and hyperextension of the hips bilaterally

B. The client with​ right-sided paralysis flexing and extending only the left knee ​Rationale: The client can use the left side to help flex and extend the right knee. Both sides should be exercised. All the other​ range-of-motion exercises are appropriate.

A client who is diagnosed with a stroke has an order for a tissue plasminogen activator​ (tPA). Which circumstance does the nurse suspect is​ present? A. Atherosclerotic buildup in affected arteries must be greater than​ 90%. B. The stroke must have occurred within 3 hours of administering the medication. C. Aspirin therapy must have been received for 6 months for tPA to be effective. D. The stroke must be hemorrhagic in nature.

B. The stroke must have occurred within 3 hours of administering the medication. Rationale: For the safe administration of​ tPA, the medication must be administered within 3 hours of the onset of the symptoms of stroke. The stroke cannot be hemorrhagic in nature because the action of the medication is to dissolve the​ clot, which would not be intended for a reclotted ruptured hemorrhagic vessel. There is no minimal or maximal degree of plaque buildup that is necessary for the safe administration of the medication. Aspirin therapy is not a requirement for tPA to be administered.

Adolescent and young adult women are at a greater risk for thrombosis. Which accurately explains one reason for the increased​ risk? A. Increased incidence of sepsis B. Use of contraceptives containing estrogen and progestin C. Increased blood volume and pressure in the bilateral lower extremities D. Prematurity at birth

B. Use of contraceptives containing estrogen and progestin ​Rationale: Estrogen in contraceptives or in hormone replacement therapy increases the risk for thrombosis. Prematurity at​ birth, increased risk of​ sepsis, and increased blood volume and pressure do not explain why women have a greater risk for thrombosis.

Which factor places older adults at an increased risk for deep venous​ thrombosis? (Select all that​ apply.) A. Decreased venous stasis B. Use of​ estrogen-containing drugs C. False positive​ D-dimers D. Limited mobility E. Multiple comorbidities

B. Use of​ estrogen-containing drugs C. False positive​ D-dimers D. Limited mobility E. Multiple comorbidities Rationale: Older adults are at an increased risk for deep venous thrombosis due to limited​ mobility, multiple​ comorbidities, false positive​ D-dimers, increased venous​ stasis, and use of​ estrogen-containing drugs.

A client with a diagnosis of deep venous thrombosis is being discharged on warfarin therapy. Which statement should the nurse include in discharge​ teaching? (Select all that​ apply). A. ​"You will need to begin taking the warfarin 4 days after stopping the​ heparin." B. ​"Avoid garlic, green​ tea, or gingko supplements while taking​ warfarin." C. "Regular follow-up and blood tests will be​ necessary." D. "If bleeding​ occurs, take your scheduled dose of warfarin and call your healthcare​ provider." E. "Use a​ soft-bristle toothbrush."

B. ​"Avoid garlic, green​ tea, or gingko supplements while taking​ warfarin." C. "Regular follow-up and blood tests will be​ necessary." E. "Use a​ soft-bristle toothbrush." Rationale: Use of a​ soft-bristle toothbrush will reduce bleeding risk. Regular​ follow-up and blood tests are necessary to ensure the warfarin therapy remains in therapeutic range.​ Garlic, green​ tea, and gingko can increase the risk of bleeding while taking warfarin. Warfarin takes 4-5 days to become effective and should be started before heparin is discontinued. If bleeding​ occurs, the dose of warfarin should be skipped and the healthcare provider notified immediately.

A nurse working in the Emergency Department is aware that there are various cultural and ethnic risk factors for stroke. The nurse understands that which of the following is an example of this? A) African-Americans have an increased incidence of intracerebral hemorrhage. B) Hispanics have almost twice the number of first-ever strokes compared with whites. C) African-Americans are more likely to die following a stroke than whites. D) The prevalence of hypertension among Hispanics is the highest in the world.

C) African-Americans are more likely to die following a stroke than whites. Rationale: African-Americans are more likely to die following a stroke than whites. Also, African-Americans have the highest prevalence of hypertension in the world and almost twice the number of first-ever strokes compared with whites. Hispanics have an increased incidence of intracerebral hemorrhage.

A client with peripheral vascular disease (PVD) has symptoms of intermittent claudication. The nurse caring for this client understands that intermittent claudication: A) Causes pain that occurs during periods of inactivity. B) Causes pain that increases when the legs are elevated and decreases when the legs are dependent. C) Causes cramping or aching pain in the lower extremities and the buttocks that occurs with a predictable level of activity. D) Is often described as a burning sensation in the lower legs.

C) Causes cramping or aching pain in the lower extremities and the buttocks that occurs with a predictable level of activity. Rationale: Intermittent claudication is a cramping or aching pain in the calves of the legs, the thighs, and the buttocks that occurs with a predictable level of activity. The pain is often accompanied by weakness and is relieved by rest.

The nurse is planning care for a client with deep venous thrombosis. Which nursing diagnosis would be a priority for this client? A) Risk for Infection related to obstructed venous return B) Excess Fluid Volume related to tissue edema C) Ineffective Tissue Perfusion related to obstructed venous return D) Disturbed Sleep Pattern related to tissue hypoxia

C) Ineffective Tissue Perfusion related to obstructed venous return Rationale: Ineffective Tissue Perfusion related to obstructed venous return is the correct diagnosis because it identifies the underlying cause. Excess Fluid Volume related to tissue edema and Disturbed Sleep Pattern related to tissue hypoxia are incorrect because they do not identify the underlying cause. Risk for Infection related to obstructed venous return would be a priority if complications of infection were present, however this is not the case.

A client with a suspected TIA presents to the Emergency Department with aphasia. Which is the pathophysiology causing aphasia? A) Middle cerebral artery involvement B) Posterior cerebral artery involvement C) Ischemia of the left hemisphere D) Ischemia of the right hemisphere

C) Ischemia of the left hemisphere Rationale: Aphasia occurs due to ischemia of the left hemisphere. The other choices may be involved in a TIA, but are not the causative pathology of aphasia.

A client recovering from a cesarean section is afebrile but is experiencing tenderness, localized heat, and redness of the left leg. What would be the best intervention for the client at this time? A) Encourage to ambulate freely. B) Provide aspirin 650 mg by mouth. C) Place on bed rest. D) Provide Methergine IM.

C) Place on bed rest. Rationale: These symptoms indicate the presence of superficial thrombophlebitis. The treatment involves bed rest and elevation of the affected limb, analgesics, and the use of elastic support hose. Ambulation would increase the inflammation. Aspirin does have anticoagulant properties but may not be the medication of choice at this time. Methergine is given only for postpartum hemorrhage and would cause vasoconstriction of an already inflamed vessel.

The nurse is completing an assessment on a newly admitted client. What assessment finding would suggest to the nurse that a client is experiencing a deep venous thrombosis? A) Shortness of breath after activity B) Two-plus palpable pedal pulses C) Swelling in one leg with pitting edema D) Bilateral calf tenderness after walking up a flight of stairs

C) Swelling in one leg with pitting edema Rationale: Manifestations of deep venous thrombosis include swelling in one leg with pitting edema because the clot is obstructing the venous return from the leg. Bilateral calf tenderness may be a normal reaction to the exercise of climbing stairs. Shortness of breath that subsides after activity and two-plus palpable pulses are not manifestations of deep venous thrombosis.

A client diagnosed with a deep vein thrombosis is receiving intravenous heparin. What does the nurse identify as the priority outcome for this client? A) The client will not disturb the intravenous infusion. B) The client will comply with dietary restrictions. C) The client will not experience bleeding. D) The client will keep the right leg elevated on two pillows.

C) The client will not experience bleeding. Rationale: An absence of bleeding is a priority outcome for any client receiving anticoagulant therapy. Disturbing the intravenous line could relate to bleeding, but this does not directly correlate with heparin. Dietary restrictions are important but not as high a priority as an absence of bleeding. Elevation of the affected extremity is important but not as high a priority as an absence of bleeding.

A client with peripheral vascular disease asks the nurse what types of exercise would improve the client's condition and overall health. About what should the nurse instruct this client? A) Bicycling B) Weight lifting C) Yoga D) Jogging

C) Yoga Rationale: Yoga is considered a complementary therapy used to reduce stress and improve circulation. Jogging, weight lifting, and bicycling may or may not help improve the client's diagnosis of peripheral vascular disease.

The nurse is observing the unlicensed assistive personnel​ (UAP) helping a client with unilateral neglect of the right side perform​ self-care. Which statement by the UAP requires an intervention by the​ nurse? A. ​"The occupational therapist will teach you how to promote upper extremity​ strength." B. ​"The occupational therapist will assist you in learning to walk using a​ walker." C. "When getting​ dressed, first put clothing on the left​ side." D. "Use the left arm to​ bathe, brush​ teeth, comb​ hair, and​ eat."

C. "When getting​ dressed, first put clothing on the left​ side." Rationale: The client should be taught to dress the affected extremities first and then the unaffected extremities. This will enable the client to dress herself with minimal assistance. The other options are all appropriate instructions to teach the client to perform​ self-care.

A client has a history of transient ischemic attacks​ (TIAs). Which medication does the nurse expect to find in the​ client's list of​ prescriptions? A. Stool softener B. Anticoagulant C. Antiplatelet D. Beta blocker

C. Antiplatelet ​Rationale: An antiplatelet may be prescribed for clients who have TIAs or who have had previous strokes. Its purpose is to prevent clot formation with the resulting vessel occlusion. An oral anticoagulant medication may be prescribed shortly after a stroke to prevent blood clot formation and to enhance cerebral blood flow by keeping the blood thin. A beta blocker is useful for lowering blood pressure but is limited in preventing stroke. Docusate sodium​ (Colace) is a stool softener that may be prescribed after a stroke to prevent straining at​ stool, which increases intracranial pressure​ (ICP).

The nurse is teaching a client about the cause of a transient ischemic attack​ (TIA). Which should the nurse​ include? A. Vascular blockage B. Sudden intracranial bleed C. Brief period of a neurologic deficit D. Formation of a clot in a blood vessel

C. Brief period of a neurologic deficit ​Rationale: A TIA is a type of ischemic stroke resulting from a localized neurologic deficit lasting 24 hours or less. Vascular blockage is the cause of an embolic stroke. Intracranial bleeds cause hemorrhagic strokes. A thrombotic stroke is the result of the formation of a clot in a blood vessel.

The nurse is performing an assessment on a client with peripheral vascular disease​ (PVD). Which finding should the nurse​ expect? A. Dilated blood vessels in the eye B. Wheezing upon auscultation of the lungs C. Delayed capillary refill in the lower extremities D. Decreased sensation of the upper extremities

C. Delayed capillary refill in the lower extremities Rationale: Delayed capillary refill in the lower extremities may be present in the client with PVD. The other clinical manifestations are not present in the client with PVD.

The nurse is talking to a client with peripheral vascular disease​ (PVD) who reports using biofeedback as a complementary therapy. The nurse knows this serves which purpose for​ PVD? A. Lowering overall cholesterol B. Reducing stress C. Improving peripheral circulation D. Decreasing arterial plaque buildup

C. Improving peripheral circulation Rationale: Biofeedback is used to improve peripheral​ circulation; biofeedback does not reduce plaque buildup. Exercise and a change in diet can reduce overall cholesterol and slow the progress of PVD. Many alternative therapies are used to reduce​ stress, but that is not a main function of biofeedback.

The nurse is reviewing documentation of a physical examination of a client who is suspected of having a stroke. Which documentation requires​ follow-up? A. Right-sided grip stronger than​ left-sided grip B. Stroke scale completed C. Onset of facial drooping at 1430 D. Alert and oriented to person but not oriented to place or time

C. Onset of facial drooping at 1430 Rationale: Time of onset of stroke symptoms should be included in the client interview. All other assessments are part of the physical assessment.

A client with chronic peripheral vascular disease​ (PVD) reports continuous pain in the bilateral lower extremities at rest and has pregangrenous lesions on his left foot. The nurse should expect to prepare the client for which collaborative​ intervention? A. Semirigid boots B. Intense pulsed light​ (IPL) C. Revascularization surgery D. Smoking cessation classes

C. Revascularization surgery Rationale: When PVD is severe enough to cause pain with rest and pregangrenous or gangrenous​ lesions, revascularization therapy is likely necessary. IPL and semirigid boots are used to treat stasis pigmentation. Although smoking cessation is vital in the treatment of​ PVD, there is no information in this scenario that the client smokes.​ Additionally, smoking cessation alone will not treat severe PVD.

The nurse is teaching a client about the endarterectomy she will undergo soon for peripheral atherosclerosis. Which statement should the nurse include in the​ teaching? A. The purpose of an endarterectomy is to vaporize the occluding material. B. An endarterectomy allows for the placement of a bypass graft. C. The purpose of an endarterectomy is to remove plaque from the artery. D. An endarterectomy is the first choice of treatment for peripheral atherosclerosis.

C. The purpose of an endarterectomy is to remove plaque from the artery. Rationale: An endarterectomy is performed to remove plaque from an occluded artery. Laser or thermal angioplasty is used to vaporize occluding material. Surgery is not a first​ choice, but is performed if symptoms are​ progressive, severe, or disabling. Bypass grafts are placed during bypass graft surgery.

A client recovering from a stroke is being discharged on warfarin sodium (Coumadin). During discharge teaching, which statement by the client would reflect an understanding of the effects of this medication? A) "It will be okay for me to eat anything, as long as it is low-fat." B) "I will stop taking this medicine if I notice any bruising." C) "I'll check my blood pressure frequently while taking this medication." D) "I will not eat spinach while I'm taking this medicine."

D) "I will not eat spinach while I'm taking this medicine." Rationale: Warfarin sodium suppresses the synthesis of vitamin K coagulation factors. Green, leafy vegetables contain vitamin K and will therefore interfere with the therapeutic effects of the drug. Bruising is a common side effect, and the drug should not be stopped unless prescribed by the physician. Low-fat foods do not interfere with warfarin sodium therapy. Anticoagulants do not affect the blood pressure.

A home care nurse is applying an Unna boot on a client with a stasis ulcer. Which statement will the nurse include when providing client education regarding this therapy? A) "A nurse will change this dressing every 2 days." B) "It is important that you maintain strict bed rest." C) "The dressing will be applied to the entire length of your leg." D) "The dressing I am applying is semi-rigid."

D) "The dressing I am applying is semi-rigid." Rationale: The Unna boot therapy is a semi-rigid dressing used to treat stasis ulcers. The dressing will be changed every 1-2 weeks, depending on ulcer drainage. The dressing allows a client to be ambulatory and does not make the client maintain strict bed rest. The dressing covers the lower leg and part of the thigh but not the entire leg.

A client diagnosed with a stroke is going to receive treatment with fibrinolytic therapy using the recombinant tissue plasminogen activator alteplase. What should the nurse explain to the client's family about the use of this medication? A) Used to treat thrombotic and hemorrhagic strokes B) Not associated with serious complications C) Indicated if the stroke symptoms have occurred within the last 6 hours D) Administered to dissolve the clot that is occluding the cerebral circulation and reestablish circulation to the involved part of the brain

D) Administered to dissolve the clot that is occluding the cerebral circulation and reestablish circulation to the involved part of the brain Rationale: Thrombolytic therapy using recombinant tissue plasminogen activator is used to dissolve the clot formed with a thrombotic stroke. Dissolving the clot reestablishes cerebral circulation. The treatment can be used if the symptoms have occurred within the last 3 hours. Bleeding is a complication associated with the treatment, which may result in cerebral hemorrhage causing extensive brain damage and disability. The treatment is only used with thrombotic strokes.

A client, diagnosed with Impaired Swallowing, complains of frequent heartburn. What should the nurse do? A) Teach the client the "chin tuck" technique when swallowing. B) Assist the client to a 90° sitting position, or as high as tolerated, during meals. C) Check the client's mouth for pocketing of food. D) Assist the client in maintaining a sitting position for 30 minutes after the meal.

D) Assist the client in maintaining a sitting position for 30 minutes after the meal. Rationale: Keeping the client upright for a time after the meal will help prevent food from being regurgitated back into the esophagus. The position of the client during the meals as well as teaching the "chin tuck" technique will assist with the swallowing mechanism but will not help with regurgitation. Pocketing food does not cause regurgitation.

The nurse is instructing the spouse of a client with a stroke on how to do passive range of motion to the affected limbs. What should the nurse explain regarding the purpose of these exercises? A) Improve muscle strength. B) Maintain cardiopulmonary function. C) Improve endurance. D) Maintain joint flexibility.

D) Maintain joint flexibility. Rationale: Passive range-of-motion exercises help to maintain joint flexibility. Active range-of-motion exercises improve muscle strength, improve endurance, and can help maintain cardiopulmonary functioning. The nurse should instruct the spouse that the exercises will help with joint flexibility.

The nurse identifies the diagnosis Ineffective Peripheral Tissue Perfusion related to decreased arterial flow to extremities as appropriate for a client. What should the nurse instruct the client to do to improve blood flow? A) Cross the legs at the knees when seated. B) Use a heating pad to increase warmth. C) Elevate the feet while reclining. D) Position with the extremities dependent.

D) Position with the extremities dependent. Rationale: Positioning with the extremities dependent is correct because gravity promotes arterial flow to the dependent extremity, increasing tissue perfusion. Crossing the legs at the knees when seated is not recommended because this position compresses partially obstructed arteries and impairs blood flow. Elevating the feet while reclining is not recommended because elevating the feet works against gravity and will further impede blood flow. Using a heating pad to increase warmth is not recommended because external heating devices could increase the risk of burns in a client with impaired circulation and decreased sensation.

The nurse is planning care for a group of clients. Which client should the nurse realize has the greatest risk for developing deep venous thrombosis? A) The client recovering from laparoscopic gallbladder surgery B) The client admitted with new-onset type II diabetes mellitus C) The client admitted with community-acquired pneumonia D) The client recovering from knee replacement surgery

D) The client recovering from knee replacement surgery Rationale: Up to 60% of clients recovering from total knee replacement surgery can develop a deep venous thrombosis. This is because of the procedure and prolonged immobility after surgery. The client admitted with new-onset type II diabetes mellitus, the client admitted with community-acquired pneumonia, and the client recovering from laparoscopic gallbladder surgery would be at a lower risk for deep venous thrombosis because prolonged immobility will not occur.

A home health nurse is caring for a client with peripheral vascular disease​ (PVD). When teaching the client regarding foot and leg​ care, which statement should the nurse​ include? (Select all that​ apply.) A. ​"When swimming, ensure the water is​ cool, not​ warm." B. "Avoid using powder on your​ feet." C. "Buy shoes in the​ morning, when feet are​ largest." D. "Apply moisturizing cream to feet and legs​ daily." E. "Dry between your toes after​ showering."

D. "Apply moisturizing cream to feet and legs​ daily." E. "Dry between your toes after​ showering." ​Rationale: Foot and leg care for clients with PVD includes applying moisturizing cream to feet and legs daily as well as drying between the toes after showering. The client should use powder on the feet to keep feet dry. When​ swimming, water should be warm because cool water causes​ vasospasm, worsening the​ client's condition. The client should buy shoes in the​ afternoon, when feet are largest.

A nurse is teaching a client about aspirin for peripheral vascular disease​ (PVD). Which client statement indicates that teaching has been​ successful? A. ​"This medication will help decrease the plaque in my​ arteries." B. "This medication will open my arteries and increase blood flow to my​ legs." C. "This medication will thin out my blood so it flows​ easier." D. "This medication will prevent me from developing a blood​ clot."

D. "This medication will prevent me from developing a blood​ clot." Rationale: Aspirin, an​ antiplatelet, is prescribed in PVD to prevent clot formation. Aspirin does not​ vasodilate, decrease​ viscosity, or help decrease plaque in the arteries. Pentoxifylline​ (Trental) decreases blood viscosity and Cilostazol​ (Pletal) decreases blood viscosity in addition to preventing further clots.

The nurse is preparing to teach a client with a venous stasis ulcer on the left lower leg. Which intervention should the nurse include in the teaching​ plan? A. Purpose of antibiotic therapy B. How to keep the wound bed clean and dry C. Increased carbohydrate intake to promote wound healing D. Application of elastic compression stockings

D. Application of elastic compression stockings ​Rationale: Use of elastic compression stockings is essential to healing of venous stasis ulcers. High dietary intake of​ protein, rather than​ carbohydrates, is needed for wound healing. Antibiotics are not routinely used for venous ulcers. Moist dressings are used for venous stasis​ ulcers, not dry dressings.

The nurse is caring for a client diagnosed with a deep venous thrombosis. Which nursing assessment is a priority​? A. EKG rhythm and rate B. Level of consciousness C. Stroke scale assessment D. Bilateral breath sounds

D. Bilateral breath sounds Rationale: Pulmonary embolism is a complication of DVT. Assessing the​ client's respiratory​ status, including auscultating bilateral breath​ sounds, is appropriate. The​ client's airway and breathing take priority. Atrial fibrillation and ischemic stroke are risk factors for development of DVT. Assessing level of consciousness and performing a stroke scale assessment are appropriate to assess for ischemic stroke. Obtaining EKG rhythm and rate is appropriate to assess for atrial fibrillation.

After performing swallowing studies for a client recovering from a​ stroke, the speech therapist recommends a pureed diet and​ honey-thick liquids. Which is a priority for the​ nurse? A. Ordering a pureed diet B. Documenting the results of the swallowing studies C. Calling the healthcare provider about the results D. Carefully monitoring for coughing after giving the client a thickened beverage

D. Carefully monitoring for coughing after giving the client a thickened beverage Rationale: Maintaining client safety is a priority when feeding for the first time. While all the answer options are​ appropriate, the priority is to assess the client for coughing when eating or drinking a thickened liquid

The nurse is caring for a client who had a total hip replacement 8 hours ago. The nurse should question which​ order? A. Begin early mobilization and leg exercises. B. Begin prophylactic anticoagulant therapy per protocol. C. Apply an intermittent pneumatic compression device. D. Keep foot of bed flat and knees straight.

D. Keep foot of bed flat and knees straight. ​Rationale: Elevating the foot of the bed and keeping the knees slightly flexed will promote venous return and decrease the risk of DVT. Early​ mobilization, prophylactic anticoagulant​ therapy, compression​ stockings, and pneumatic compression devices are used to prevent DVT.

A client at 27​ weeks' gestation is diagnosed with deep venous thrombosis. Which collaborative therapy should the nurse​ anticipate? A. Increased risk of hemorrhage after delivery B. Prescription for warfarin therapy C. Immediate emergency cesarean section D. Prescription for heparin therapy

D. Prescription for heparin therapy Rationale: Heparin therapy is considered safe during pregnancy because heparin does not cross the placenta. Warfarin does cross the placenta and may cause congenital​ malformations; therefore, it is contraindicated during pregnancy. An emergency cesarean section is not indicated with the information provided. Even if the client is on heparin​ therapy, there is not an increased risk of hemorrhage after delivery.

The nurse on the stroke rehabilitation unit is planning care for a client who is experiencing vision and equilibrium​ deficits, altered​ proprioception, hemianopia, and neglect syndrome. Which nursing therapy is the most important to​ include? A. Maintaining​ fluid, oxygen, and nutritional status B. Developing an alternate means of communicating C. Providing behavioral and cognitive therapy when the condition stabilizes D. Providing reassurance and support

D. Providing reassurance and support ​Rationale: The client with​ sensory-perceptual deficits needs reassurance and support. There is no indication that the client cannot maintain​ fluid, oxygen, and nutritional​ status, cannot communicate​ well, or has cognitive or behavioral changes.

An adult client had a stroke involving the internal carotid artery of the dominant hemisphere. The nurse should anticipate that the client will have difficulty with which​ function? A. Swallowing B. Retaining urine C. Staying alert D. Speaking

D. Speaking Rationale: Clinical manifestations of a stroke involving the internal carotid artery include contralateral paralysis of face and​ limbs, contralateral sensory deficits of face and​ limbs, aphasia,​ apraxia, agnosia, unilateral​ neglect, and homonymous hemianopia. Difficulty​ swallowing, drowsiness, and urine retention are not expected in this type of stroke.

The nurse is teaching a client about lifestyle modifications to promote vasodilation in a client with peripheral vascular disease​ (PVD). Which intervention should the nurse​ suggest? A. Walk daily. B. Take an aspirin daily. C. Wash extremities in cool water. D. Stop smoking.

D. Stop smoking. Rationale: Smoking causes​ vasoconstriction, so stopping smoking will improve vasodilation. Increasing activity such as walking may lead to collateral circulation but does not cause vasodilation. The use of aspirin may impede platelet clumping but does not cause vasodilation. Cool water may cause vasoconstriction to occur.

The nurse is planning care for a client who has unilateral neglect and​ left-sided paralysis after experiencing a thrombotic stroke. Which goal of care should the nurse​ choose? A. The client will improve communication techniques. B. The client will maintain bedrest. C. The​ client's blood pressure will remain within​ 40% of normal. D. The client will participate in therapies to prevent contractures.

D. The client will participate in therapies to prevent contractures. ​Rationale: Preventing contractures is a good goal for a client with​ left-sided paralysis and unilateral neglect. The client will be taught active​ range-of-motion exercises and ambulate as​ able, so maintaining bedrest is not appropriate. An appropriate goal for blood pressure is within normal​ limits, rather than​ 40% of normal. There is no indication that the client needs assistance with communication.

The nurse is caring for a client who is scheduled for placement of a filter in the vena cava. The nurse should intervene if the client makes which​ statement? A. "The procedure has a low risk of​ mortality." B. "The filter will trap clots to prevent them from reaching my​ lungs." C. "Local anesthesia will be used for the placement of the​ filter." D. ​"The filter will increase my risk of​ bleeding."

D. ​"The filter will increase my risk of​ bleeding." ​Rationale: Vena cava filters will not increase the​ client's risk of bleeding. Placement of vena cava filters has a low mortality and morbidity and is completed under local anesthesia. The purpose of the filter is to trap thrombi before they enter the lungs and cause pulmonary embolism.

The nurse is assessing a client diagnosed with chronic vascular insufficiency​ (CVI). Which assessment finding should the nurse​ expect? (Select all that​ apply.) A. Lower extremity edema B. Cyanosis of lower legs C. Excessive hair growth on the legs D. Soft subcutaneous tissue on affected areas on leg E. Pale skin on lower legs

​A. Lower extremity edema B. Cyanosis of lower legs Rationale: Manifestations of CVI include lower extremity edema that worsens with​ standing; itching, dull leg discomfort or pain that increases with​ standing; thin,​ shiny, atrophic​ skin; cyanosis and brown skin pigmentation of lower leg and​ foot; possible weeping​ dermatitis; thick, fibrous​ (hard) subcutaneous​ tissue; and recurrent ulcerations of medial or anterior ankles.