Ch 26: Vascular Disorders and problems of Peripheral Disorders PrepU

A nurse is teaching a client who will soon be discharged with a prescription for warfarin (Coumadin). Which statement should the nurse include in discharge teaching?

"Don't take aspirin while you're taking warfarin." Explanation: Because aspirin decreases platelet aggregation and interferes with clotting, concomitant use of aspirin with warfarin, an anticoagulant, may lead to excessive anticoagulant effects — and bleeding. Warfarin therapy is most effective with consistent dietary intake of vitamin K. Increase intake of foods rich in vitamin K, such as broccoli, could change the client's warfarin dose requirements. Although warfarin interrupts the normal clotting cycle, it doesn't dissolve clots that have already formed. The client should take warfarin exactly as ordered to maintain the desired level of anticoagulation. Doubling a dose could cause bleeding.

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

0.50 Explanation: After the circulatory status has been assessed and determined to be adequate for healing (ABI of more than 0.5) (Mosti, Iabichella, & Partsch, 2012), surgical dressings can be used to promote a moist environment.

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

1.5 to 2.5 Explanation: Heparin therapy is usually considered therapeutic when the aPTT is 1.5 to 2.5 times the normal aPTT value. The other values are not within therapeutic range.

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

Abdomen bruit Explanation: A pulsating mass or a bruit in the abdomen over the mass is most suggestive of aortic aneurysm. Severe back pain, nausea, and high blood pressure are all symptoms associated with aortic aneurysm but not as independently suggestive.

Which nursing problem statement is most significant in planning the care for a client with Raynaud syndrome?

Acute pain Explanation: The hallmark symptom of Raynaud syndrome is acute pain related to the arterial insufficiency. ADL Deficit, Coping Impairment, and Activity Intolerance can occur but are less significant than Acute Pain

The nurse is caring for a client with cellulitis of the left foot. Which treatment will the nurse expect to be prescribed for this client? Select all that apply.

Administer cephalexin Elevate the extremity Apply cool packs every 2 to 4 hours Apply graduated compression stocking to the foot Explanation: Cellulitis occurs when an entry point through broken skin allows microbes to enter and release their toxins in the subcutaneous tissues. The etiologic pathogen of cellulitis is typically either Streptococcus species or Staphylococcus aureus. Treatment of cellulitis includes antibiotics such as cephalexin. The extremity should be elevated 3 to 6 inches above heart level and cool packs applied to the site every 2 to 4 hours until the inflammation subsides. Graduated compression stockings are used to reduce the risk of recurrence of cellulitis. Light massage is not indicated for cellulitis.

Which of the following medications is considered a thrombolytic?

Alteplase Explanation: Alteplase is considered a thrombolytic, which lyses and dissolves thrombi. Thrombolytic therapy is most effective when given within the first 3 days after acute thrombosis. Heparin, Coumadin, and Lovenox do not lyse clots.

To assess the dorsalis pedis artery, the nurse would use the tips of three fingers and apply light pressure to the:

Anterior surface of the foot near the ankle joint. Explanation: The dorsalis pedis pulse can be palpated on the dorsal surface of the foot distal to the major prominence of the navicular bone.

A client in the emergency department states, "I have always taken a morning walk, but lately my leg cramps and hurts after just a few minutes of walking. The pain goes away after I stop walking, though." Based on this statement, which priority assessment should the nurse complete?

Attempt to palpate the dorsalis pedis and posterior tibial pulses. Explanation: Intermittent claudication is a sign of peripheral arterial insufficiency. The nurse should assess for other clinical manifestations of peripheral arterial disease in a client who describes intermittent claudication. A thorough assessment of the client's skin color and temperature and the character of the peripheral pulses are important in the diagnosis of arterial disorders.

The nurse is caring for a client with Raynaud's disease. What are important instructions for a client who is diagnosed with this disease to prevent an attack?

Avoid situations that contribute to ischemic episodes. Explanation: Teaching for clients with Raynaud's disease and their family members is important. The nurse should instruct the clients to avoid situations that contribute to ischemic episodes. Reporting changes in the usual pattern of chest pain or avoiding fatty foods and exercise does not help the client to avoid an attack; it is more contributory for clients with CAD. In addition, the nurse advises clients to avoid over-the-counter decongestants.

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

BP of 160/110 mm Hg Explanation: Hypertension is considered a major risk factor for PAD. Blood pressure should be less than 130/90 mm Hg. The other laboratory results are within the recommended range of normal to high normal.

A client is recovering from surgical repair of a dissecting aortic aneurysm. Which assessment findings indicate possible bleeding or recurring dissection?

Blood pressure of 82/40 mm Hg and heart rate of 125 beats/minute Explanation: Assessment findings that indicate possible bleeding or recurring dissection include hypotension with reflex tachycardia (as evidenced by a blood pressure of 82/40 mm Hg and a heart rate of 125 beats/minute), decreased urine output, and unequal or absent peripheral pulses. Hematuria, increased urine output, and bradycardia aren't signs of bleeding from aneurysm repair or recurring dissection.

Which observation regarding ulcer formation on the client's lower extremity indicates that the ulcer is a result of venous insufficiency?

Border of the ulcer is irregular Explanation: The border of an ulcer caused by arterial insufficiency is circular. Superficial venous insufficiency ulcers cause minimal pain. The base of a venous insufficiency ulcer shows a beefy red to fibrinous yellow color. Venous insufficiency ulcers are usually super

The most common site of aneurysm formation is in the: Which observation regarding ulcer formation on the client's lower extremity indicates that the ulcer is a result of venous insufficiency?

Border of the ulcer is irregular Explanation: The border of an ulcer caused by arterial insufficiency is circular. Superficial venous insufficiency ulcers cause minimal pain. The base of a venous insufficiency ulcer shows a beefy red to fibrinous yellow color. Venous insufficiency ulcers are usually superficial.

Which of the following is a characteristic of an arterial ulcer?

Border regular and well demarcated Explanation: Characteristics of an arterial ulcer include a border that is regular and demarcated. Brawny edema, ABI > 0.90, and edema that may be severe are characteristics of a venous ulcer.

The nurse assesses a patient with hip pain related to intermittent claudication. She knows that the area of arterial narrowing is the:

Common iliac artery. Explanation: The location of the claudication occurs in muscle groups distal to the diseased vessel. Hip or buttock pain may result from reduced blood flow from the common iliac artery.

The nurse is caring for a client recovering from acute axillary lymphangitis. Which treatment will the nurse anticipate being prescribed for this client after antibiotic therapy has concluded?

Compression sleeve Explanation: Lymphangitis is an acute inflammation of the lymphatic channels. It arises most commonly from a focal area of infection in an extremity caused by bacteria. At the conclusion of antibiotic therapy used for an acute attack, a graduated compression sleeve should be worn on the affected extremity for several months to prevent long-term edema. An arm sling is not required. The client will not need aspirin therapy as there is no surgery and/or risk of clots. The client will not need physical therapy as there should be no lingering effects from treatment of lymphangitis.

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

Causes vasospasm Reduces circulation to the extremities Impairs transport and cellular use of oxygen Increases blood viscosity Explanation: Nicotine from tobacco products causes vasospasm and can dramatically reduce circulation to the extremities. Tobacco smoke also impairs transport and cellular use of oxygen and increases blood viscosity.

Health teaching includes advising patients on ways to reduce PAD. The nurse should always emphasize that the strongest risk factor for the development of atherosclerotic lesions is:

Cigarette smoking. Explanation: Nicotine decreases blood flow, increases heart rate and blood pressure, and increases the risk for clot formation by increasing platelet aggregation. Smokers have a four-fold higher risk of developing pain from arterial disease than nonsmokers. Carbon monoxide, produced by burning tobacco, combines with hemoglobin more readily than oxygen, thus depriving tissues of oxygen.

Pentoxifylline (Trental) is a medication used for which of the following conditions?

Claudication Explanation: Trental and Pletal are the only medications specifically indicated for the treatment of claudication. Thromboemboli, hypertension, and elevated triglycerides are not indications for using Trental.

A patient is suspected to have a thoracic aortic aneurysm. What diagnostic test(s) does the nurse anticipate preparing the patient for? (Select all that apply.)

Computed tomography Transesophageal echocardiography X-ray Explanation: Diagnosis of a thoracic aortic aneurysm is principally made by chest x-ray, computed tomography angiography (CTA), and transesophageal echocardiography (TEE).

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

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

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

Myocardial infarction (MI) Explanation: Aortic dissection may be mistaken for an acute MI, which could confuse the clinical picture and initial treatment. Aortic dissection is not mistaken for stroke, pneumothorax, or angina.

Which is a characteristic of arterial insufficiency?

Diminished or absent pulses Explanation: A diminished or absent pulse is a characteristic of arterial insufficiency. Venous characteristics include superficial ulcer formation, an aching and cramping pain, and presence of pulses.

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

Diminished or absent pulses Explanation: Occlusive arterial disease impairs blood flow and can reduce or obliterate palpable pulsations in the extremities. A diminished or absent pulse is a characteristic of arterial insufficiency.

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

Dissecting Explanation: Dissection results from a rupture in the intimal layer, resulting in bleeding between the intimal and medial layers of the arterial wall. Saccular aneurysms collect blood in the weakened outpouching. In a false aneurysm, the mass is actually a pulsating hematoma. An anastomotic aneurysm occurs as a result of infection at arterial suture or graft sites.

A client with venous insufficiency asks the nurse what they can do to decrease their risk of complications. What advice should the nurse provide to clients with venous insufficiency?

Elevate the legs periodically for at least 15 to 20 minutes. Explanation: The nurse should advise the client to periodically elevate the legs for at least 15 to 20 minutes. Avoiding foods with iodine or refraining from sexual activity for a week does not relate to venous insufficiency.

A client with peripheral artery disease (PAD) has limited access to supervised exercise therapy (SET). Which recommendation will the nurse make to help the client's intermittent claudication?

Engage in an unsupervised walking program. Explanation: Generally, clients feel better and have fewer symptoms of claudication after participating in a SET program. However unsupervised walking exercise programs are attractive for many clients with PAD with limited access to a SET program. Based upon research studies, home-based programs may be a viable and efficacious option for clients unable to participate in a structured, on-site, supervised exercise program. Sleeping with the legs in a horizontal position increases the pain. The health care provider will prescribe medications appropriate for the client. It is beyond the nurse's scope of practice to recommend a medication. Elevating the lower extremities increases the pain.

A patient is having an angiography to detect the presence of an aneurysm. After the contrast is administered by the interventionist, the patient begins to complain of nausea and difficulty breathing. What medication is a priority to administer at this time?

Epinephrine Explanation: Infrequently, a patient may have an immediate or delayed allergic reaction to the iodine contained in the contrast agent used in angiography. Manifestations include dyspnea, nausea and vomiting, sweating, tachycardia, and numbness of the extremities. Any such reaction must be reported to the interventionalist at once; treatment may include the administration of epinephrine, antihistamines, or corticosteroids.

Which class of medication lyses and dissolves thrombi?

Fibrinolytic Explanation: Thrombolytic (fibrinolytic) therapy lyses and dissolves thrombi in 50% of clients. Anticoagulants, platelet inhibitors, and factor XA inhibitors do not lyse or dissolve thrombi.

Which of the following are complications of percutaneous transluminal balloon angioplasty (PTA)? Select all that apply.

Hematoma Embolization Dissection of the vessel Bleeding Stent migration Explanation: PTA is used to treat artherosclerosis. A balloon-tipped catheter is maneuvered across the area of stenosis, and a stent (small mesh tube) may be inserted to support the blood vessel walls and prevent collapse. Complications from PTA include hematoma, embolization, dissection of the vessel, bleeding, intimal damage (dissection), and stent migration.

A nurse is completing an assessment on a client and discovers an enlarged, red, and tender lymph node. The nurse will describe and document the lymph node using which term?

Lymphadenitis Explanation: Acute lymphadenitis is demonstrated by enlarged, red, and tender lymph nodes. Lymphangitis is acute inflammation of the lymphatic channels. Lymphedema is demonstrated by swelling of tissues in the extremities because of an increased quantity of lymph that results from an obstruction of lymphatic vessels. Elephantiasis refers to a condition in which chronic swelling of the extremity recedes only slightly with elevation.

A client is diagnosed with peripheral arterial disease. Review of the client's chart shows an ankle-brachial index (ABI) on the right of 0.45. This indicates that the right foot has which of the following?

Moderate to severe arterial insufficiency Explanation: Normal people without arterial insufficiency have an ABI of about 1.0. Those with an ABI of 0.95 to 0.5 have mild to moderate arterial insufficiency. Those with an ABI of less than 0.50 have ischemic rest pain. Those with tissue loss have severe ischemia and an ABI of 0.25 or less.

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

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

A patient with impaired renal function is scheduled for a multidetector computer tomography (MDCT) scan. What preprocedure medication may the nurse administer to this patient?

Oral N-acetylcysteine Explanation: Patients with impaired renal function scheduled for MDCT may require preprocedural treatment to prevent contrast-induced nephropathy. This may include oral or IV hydration 12 hours preprocedure; administration of oral N-acetylcysteine, which acts as an antioxidant; and/or administration of sodium bicarbonate, which alkalinizes urine and protects against free radical damage (Rundback, Nahl, & Yoo, 2011).

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

Posterior tibial. Explanation: Clinical symptoms of PAD are manifested in organs or muscle groups supplied by specific arterial blood flow. The posterior tibial artery is a major artery that is a common site for occlusion.

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

Risk factor modification Explanation: Risk factor modification is the most effective intervention for preventing progression of vascular disease. Measures to prevent tissue loss and amputation are a high priority. Patients are taught to avoid trauma; wear sturdy, well-fitting shoes or slippers; and use pH neutral soaps and body lotions.

Which of the following is the most common site for a dissecting aneurysm?

The thoracic area is the most common site for a dissecting aneurysm. About one-third of patients with thoracic aneurysms die of rupture of the aneurysm.

A client with a history of aching leg pain seeks medical attention for the development of a leg wound. Which assessment findings indicate to the nurse that the client is experiencing a venous ulcer? Select all that apply.

Wound is superficial Wound has an irregular border Thick, tough skin around the ankles Darkened skin around the lower extremities Explanation: Aching leg pain is a symptom of venous insufficiency. Assessment findings that indicate the client is experiencing a venous ulcer include the wound is superficial with an irregular border. Thick skin around the ankles and darkened skin around the lower extremities are additional symptoms of venous insufficiency. A pale wound base is associated with an arterial ulcer.

Which client with a venous stasis ulcer is a candidate for topical hyperbaric oxygen therapy?

a client with a chronic, nonhealing skin lesion Explanation: Chronic, nonhealing skin lesions are treated with topical hyperbaric oxygen therapy. This approach delivers oxygen above atmospheric pressure directly to the wound rather than to the full body as with other disorders such as carbon monoxide poisoning. Necrotic tissue is debrided from a stasis ulcer. A client's infection is treated with an application of Silvadene, an antibacterial cream, or an antibiotic ointment and an occlusive transparent dressing such as Tegaderm that traps moisture and speeds healing.

Two days after undergoing a total abdominal hysterectomy, a client complains of left calf pain. Venography reveals deep vein thrombosis (DVT). When assessing this client, the nurse is likely to detect:

left calf circumference 1" (2.5 cm) larger than the right. Explanation: Signs of DVT include inflammation and edema in the affected extremity, causing its circumference to exceed that of the opposite extremity. Pallor, coolness, decreased pulse, and hair loss in an extremity signal interrupted arterial blood flow, which doesn't occur in DVT.

The nurse teaches the client with peripheral vascular disease (PVD) to refrain from smoking because nicotine causes

vasospasm. Explanation: Nicotine causes vasospasm and can thereby dramatically reduce circulation to the extremities. Tobacco smoke also impairs transport and cellular use of oxygen and increases blood viscosity. Clients with arterial insufficiency who smoke or chew tobacco must be fully informed of the effects of nicotine on circulation and be encouraged to stop.

Beginning warfarin concomitantly with heparin can provide a stable INR by which day of heparin treatment?

5 Explanation: Beginning warfarin concomitantly with heparin can provide a stable INR by day 5 of heparin treatment, at which time the heparin maybe discontinued.

Following abdominal surgery, which factor predisposes a client to deep vein thrombosis?

The client will be immobile during and shortly after surgery. Explanation: Postoperative immobility and subsequent venous stasis predispose the client to deep vein thrombosis. Other predisposing factors for this condition include obesity and current pregnancy, which don't apply to this client. Exercise isn't a risk factor for deep vein thrombosis.

To check for arterial insufficiency when a client is in a supine position, the nurse should elevate the extremity at a 45-degree angle and then have the client sit up. The nurse suspects arterial insufficiency if the assessment reveals:

elevational pallor. Explanation: If arterial insufficiency is present, elevation of the limb would yield a pallor from the lack of circulation. Rubor on elevation and increased venous filling time would suggest venous problems secondary to venous trapping and incompetent valves.

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

forcing blood into the deep venous system. Explanation: Antiembolism stockings prevent DVT by forcing blood into the deep venous system, instead of allowing blood to pool. Ambulation prevents blood from pooling and prevents DVT, but encouraging ambulation isn't a function of the stockings. Antiembolism stockings could possibly provide warmth, but this factor isn't how they prevent DVT. Elevating the extremity decreases edema but doesn't prevent DVT.

The nurse explains to a patient that the primary cause of a varicose vein is:

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

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

"I will limit the amount of cigarettes I smoke." Explanation: Raynaud phenomenon is a form of intermittent arteriolar vasoconstriction that results in coldness, pain, and pallor of the fingertips or toes. Patients should avoid all forms of nicotine, which may induce attacks; this includes nicotine gum or patches used to aid smoking cessation. The client should be instructed to avoid situations that may be stressful as this could trigger an attack. Wearing gloves before opening a cold car door and when taking food out of the freezer should also be done as this could trigger vasoconstriction and an attack.

The nurse is caring for a client recovering from surgery to treat aortoiliac disease. Which assessment findings indicate to the nurse that manual manipulation of the bowel occurred during the surgery? Select all that apply.

Abdominal distention Absence of bowel sounds Explanation: The treatment of aortoiliac disease is essentially the same as that for atherosclerotic PAD. If there is significant aortic disease, the surgical procedure of choice is the aortoiliac graft. If possible, the distal graft is anastomosed to the iliac artery, and the entire surgical procedure is performed within the abdomen. Because of this, abdominal assessment for bowel sounds and paralytic ileus is to be done at least every 8 hours. Abdominal distention and the absence of bowel sounds indicate paralytic ileus. Coffee-ground emesis is an indication of gastrointestinal bleeding which is not associated with surgery to treat aortoiliac disease. A liquid bowel movement may indicate bowel ischemia which is caused by an occlusion of the mesenteric blood supply. Left lower quadrant abdominal pain is not associated with treatment of aortoiliac disease.

When teaching a client with peripheral vascular disease about foot care, a nurse should include which instruction?

Avoid wearing canvas shoes. Explanation: The client should be instructed to avoid wearing canvas shoes. Canvas shoes cause the feet to perspire, and perspiration can cause skin irritation and breakdown. Cotton and cornstarch absorb perspiration. The client should be instructed to cut toenails straight across with nail clippers.

The nurse reviews the health history of a client with atherosclerosis. For which risk factors will the nurse prepare teaching for this client? Select all that apply.

High-fat diet Exercise regimen Elevated blood pressure Use of nicotine products Explanation: Many risk factors are associated with atherosclerosis. Although it is not entirely clear whether modification of these risk factors prevents the development of cardiovascular disease, evidence indicates that it may slow the process, Because of this, the nurse will prepare teaching to address modifiable risk factors to include a high-fat diet, sedentary lifestyle, elevated blood pressure, and the use of nicotine products. Age is a nonmodifiable risk factor that cannot be changed.

A client in the ED has a 5-cm thoracic aortic aneurysm that was discovered during a routine chest x-ray. When obtaining the client's history, which symptoms will it be most important for the nurse to ask about?

Hoarse voice and difficulty swallowing Explanation: Symptoms are dyspnea, the result of pressure of the aneurysm sac against the trachea, a main bronchus, or the lung itself; cough, frequently paroxysmal and with a brassy quality; hoarseness, stridor, or weakness or complete loss of the voice (aphonia), resulting from pressure against the laryngeal nerve; and dysphagia (difficulty in swallowing) due to impingement of the aneurysm on the esophagus.

A client is recovering from sclerotherapy to treat varicose veins. Which information will the nurse provide to the client after the procedure? Select all that apply.

Increase the amount of time walking at home. Take acetaminophen as prescribed for pain. Expect a burning sensation in the injected areas for 1 to 2 days. Wear graduated compression stockings for a week after the procedure. Explanation: Sclerotherapy involves injection of an irritating chemical into a vein to produce localized phlebitis and fibrosis, thereby obliterating the lumen of the vein. This treatment may be performed alone for small varicosities or may follow vein ablation, ligation, or stripping. At home the client should be encouraged to walk to activate the calf muscle pump and maintain blood flow in the leg. Over-the-counter analgesics can be taken as prescribed for mild discomfort that can occur. A burning sensation in the injected areas may occur for 1 to 2 days after the procedure. After the sclerosing agent is injected, graduated compression stockings are applied to the leg and are worn for approximately 1 week after the procedure. The client shouldn't have any dressings to change after sclerotherapy.

The nurse is caring for a client with upper extremity arterial disease. Which assessments will the nurse include in the client's plan of care? Select all that apply.

Measure blood pressure on both arms. Assess capillary refill on both arms every 2 hours. Compare radial pulses on both wrists every 2 hours. Explanation: Arterial stenosis and occlusions occur less frequently in the upper extremities than in the legs, and cause less severe symptoms because the collateral circulation is significantly better in the arms. However symptoms of upper extremity arterial disease include arm fatigue and pain with exercise, the inability to hold or grasp objects, and possible difficulty driving. The assessment of this client includes measuring blood pressure on both upper extremities since there may be a difference of more than 15 to 20 mm Hg because of the arterial occlusion. Capillary refill should also be assessed every 2 hours along with comparing the radial pulses on both wrists every 2 hours. Activities using the affected upper extremity can cause cramping and pain. There is no evidence that the dependent position is helpful when caring for a client with upper extremity arterial disease.

The nurse is assessing a client who is experiencing symptoms of an arterial embolism of the right arm. Which assessment findings indicate to the nurse that the client has this condition? Select all that apply.

Pain Pallor Paralysis Pulselessness Explanation: Symptoms of arterial emboli depend primarily on the size of the embolus, organ involvement, and the state of collateral vessels. The symptoms of acute arterial embolism in extremities with poor collateral flow are acute, severe pain, and a gradual loss of sensory and motor function. The six Ps associated with acute arterial embolism are pain, pallor, paralysis, pulselessness, paresthesia, and poikilothermia. Palpitations are not associated with an arterial embolism.

A client is diagnosed with a large thoracic aneurysm. Which findings will the nurse expect when assessing this client? Select all that apply.

Stridor Hoarse voice Brassy cough Aphonia Explanation: The thoracic area is the most common site for a dissecting aneurysm. Symptoms vary and depend on how rapid the aneurysm dilates and how the pulsating mass affects surrounding structures. Symptoms of this type of aneurysm include stridor caused by pressure of the aneurysm against the trachea. Other symptoms include a hoarse voice, a brassy cough, and aphonia (or loss of voice) caused by pressure on the laryngeal nerve. A thoracic aneurysm does not affect pulses in the arms.

A client with a diagnosed abdominal aortic aneurysm (AAA) develops severe lower back pain. Which is the most likely cause?

The aneurysm may be preparing to rupture. Explanation: Signs of impending rupture include severe back or abdominal pain, which may be persistent or intermittent. Abdominal pain is often localized to the middle or lower abdomen to the left of the midline. Low-back pain may be present because of pressure of the aneurysm on the lumbar nerves. Indications of a rupturing AAA include constant, intense back pain; falling blood pressure; and decreasing hematocrit. Rupture into the peritoneal cavity is quickly fatal. A retroperitoneal rupture of an aneurysm may result in hematomas in the scrotum, perineum, flank, or penis.

The nurse is teaching a client who has been newly diagnosed with Raynaud syndrome. Which self-care strategies should the nurse include in the teaching? Select all that apply.

Wear gloves to protect hands from injury when performing tasks. Do not smoke, or stop smoking. Reduce emotional triggers Explanation: The nurse instructs clients with Raynaud syndrome to refrain from smoking; reduce emotional triggers, protect hands and feet from injury, and wear warm socks and mittens when going outdoors in cold weather. Stress on the ulnar nerve will not cause pain associated with Raynaud syndrome

The most important reason for a nurse to encourage a client with peripheral vascular disease to initiate a walking program is that this form of exercise:

decreases venous congestion. Explanation: Regular walking is the best way to decrease venous congestion because using the leg muscles as a pump helps return blood to the heart. Regular exercise also aids in stress reduction and weight reduction and increases the formation of HDLs — which are all beneficial to a client with peripheral vascular disease. However, these changes don't have as significant an effect on the client's condition as decreasing venous congestion.

A nurse is instructing a client about using antiembolism stockings. Antiembolism stockings help prevent deep vein thrombosis (DVT) by:A client with no known history of peripheral vascular disease comes to the emergency department complaining of sudden onset of lower leg pain. Inspection and palpation reveal absent pulses; paresthesia; and a mottled, cyanotic, cold, and cadaverous left calf. While the physician determines the appropriate therapy, the nurse should:

keep the affected leg level or slightly dependent. Explanation: While the physician makes treatment decisions, the nurse should maintain the client on bed rest, keeping the affected leg level or slightly dependent (to aid circulation) and protecting it from pressure and other trauma. Warming the leg with a heating pad (or chilling it with an ice pack) would further compromise tissue perfusion and increase injury to the leg. Elevating the leg would worsen tissue ischemia. Shaving an ischemic leg could cause accidental trauma from cuts or nicks.

A nurse is reviewing self-care measures for a client with peripheral vascular disease. Which statement indicates proper self-care measures?

"I have my wife look at the soles of my feet each day." Explanation: A client with peripheral vascular disease should examine his feet daily for redness, dryness, or cuts. If a client isn't able to do this examination on his own, then a caregiver or family member should help him. A client with peripheral vascular disease should avoid hot tubs because decreased sensation in the feet may make him unable to tell if the water is too hot. The client should always wear shoes or slippers on his feet when he is out of bed to help minimize trauma to the feet. Any type of nicotine, whether it's from cigarettes or smokeless tobacco, can cause vasoconstriction and further decrease blood supply to the extremities.

A client with peripheral arterial disease asks the nurse about using a heating pad to warm the feet. The nurse's best response is which of the following?

"It is better to put the heating pad on your abdomen, which causes vasodilation and warmth to your feet." Explanation: It is safer to apply a heating pad to the abdomen, causing a reflex vasodilation in the extremities. Heat may be applied directly to ischemic extremities; however, the temperature of the heating source must not exceed body temperature. Excess heat may increase the metabolic rate of the extremities and increase the need for oxygen beyond that provided by the reduced arterial flow through the diseased artery.

A nurse is providing education about maintaining tissue integrity to a client with peripheral arterial disease. Which of the following statements by the client indicates a need for clarification?

"Shoes made of synthetic material are best for my feet." Explanation: The client should wear leather shoes with an extra-depth toe box. Synthetic shoes do not allow air to circulate.

A client admitted to the medical-surgical unit with a venous thromboembolism (VTE) is started on enoxaparin and warfarin. The client asks the nurse why two medications are needed. Which response by the nurse is accurate?

"The enoxaparin will work immediately, but the warfarin takes several days to achieve its full effect." Explanation: Oral anticoagulants such as warfarin are monitored by the prothrombin time (PT) or the international normalized ratio (INR). Because the full anticoagulant effect of warfarin is delayed for 3 to 5 days, it is usually administered concurrently with heparin until desired anticoagulation has been achieved (i.e., when the PT is 1.5 to 2 times normal or the INR is 2.0 to 3.0).

The nurse is assisting a patient with peripheral arterial disease to ambulate in the hallway. What should the nurse include in the education of the patient during ambulation?

"Walk to the point of pain, rest until the pain subsides, then resume ambulation." Explanation: The nurse instructs the patient to walk to the point of pain, rest until the pain subsides, and then resume walking so that endurance can be increased as collateral circulation develops. Pain can serve as a guide in determining the appropriate amount of exercise.

When administering heparin anticoagulant therapy, the nurse needs to make certain that the activated partial thromboplastin time (aPTT) is within the therapeutic range of:

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

In a client with a bypass graft, the distal outflow vessel must have at least what percentage patency for the graft to remain patent?

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

A nursing instructor is discussing the diagnosis of intermittent claudication with students. To determine whether the students understand the pathophysiology of the disease, the instructor asks, "What percentage of the arterial lumen must be obstructed before intermittent claudication is experienced?" What answer should the students give?

50 Explanation: Typically, about 50% of the arterial lumen or 75% of the cross-sectional area must be obstructed before intermittent claudication is experienced.

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

50 Explanation: Typically, about 50% of the arterial lumen or 75% of the cross-sectional area must be obstructed before intermittent claudication is experienced.

A nurse suspects the presence of an abdominal aortic aneurysm. What assessment data would the nurse correlate with a diagnosis of abdominal aortic aneurysm? (Select all that apply.)

A pulsatile abdominal mass Low back pain Lower abdominal pain Explanation: Some patients complain that they can feel their heart beating in their abdomen when lying down, or they may say that they feel an abdominal mass or abdominal throbbing. The most important diagnostic indication of an abdominal aortic aneurysm is a pulsatile mass in the middle and upper abdomen. Signs of impending aneurysm rupture include severe back or abdominal pain, which may be persistent or intermittent. Abdominal pain is often localized in the middle or lower abdomen to the left of the midline. Low back pain may be present because of pressure of the aneurysm on the lumbar nerves.

The nurse is assessing a client with severe hypertension. Which symptom indicates to the nurse that the client is experiencing dissection of the aorta?

A ripping sensation in the chest Explanation: Aortic dissections are commonly associated with poorly controlled hypertension. Dissection is caused by rupture in the intimal layer. A rupture may occur through adventitia or into the lumen through the intima, allowing blood to reenter the main channel and resulting in chronic dissection or occlusion of branches of the aorta. The onset of symptoms is usually sudden and described as severe, persistent pain that feels like tearing or ripping. An aortic dissection does not cause pain and numbness of the left arm. Pain when flexing the neck forward is not associated with an aortic dissection. An aortic dissection does not cause a headache.

A patient is admitted to a special critical care unit for the treatment of an arterial thrombus. The nurse is aware that the preferred drug of choice for clot removal, unless contraindicated, would be:

Alteplase. Explanation: Alteplase has fewer disadvantages than the other thrombolytic agents. Refer to Table 18-2 in the text.

A nurse is changing a dressing on an arterial suture site. The site is red, with foul-smelling drainage. Based on these symptoms, the nurse is aware to monitor for which type of aneurysm?

Anastomotic Explanation: An anastomotic aneurysm occurs as a result of infection at arterial suture or graft sites. Dissection results from a rupture in the intimal layer, resulting in bleeding between the intimal and medial layers of the arterial wall. Saccular aneurysms collect blood in the weakened outpouching. In a false aneurysm, the mass is actually a pulsating hematoma.

Which aneurysm occurs as a result of infection at arterial suture or graft sites?

Anastomotic Explanation: An anastomotic aneurysm occurs as a result of infection, arterial wall failure, and suture or graft failure. Dissection results from a rupture in the intimal layer, resulting in bleeding between the intimal and medial layers of the arterial wall. Saccular aneurysms collect blood in the weakened outpouching. In a false aneurysm, the mass is actually a pulsating hematoma.

A client is being discharged home with a venous stasis ulcer on the right lower leg. Which topic will the nurse include in client teaching before discharge?

Application of graduated compression stockings Explanation: Graduated compression stockings usually are prescribed for clients with venous insufficiency. The required pressure gradient is determined by the amount and severity of venous disease. Graduated compression stockings are designed to apply 100% of the prescribed pressure gradient at the ankle and pressure that decreases as the stocking approaches the thigh, reducing the caliber of the superficial veins in the leg and increasing flow in the deep veins. These stockings may be knee high, thigh high, or pantyhose.

A home health nurse is seeing an elderly female client for the first time. During the physical assessment of the client's feet, the nurse notes several circular ulcers around the tips of the toes on both feet. The bases of the ulcers are pale, and the client reports the ulcers to be very painful. From these assessment findings, the nurse suspects that the cause of the ulcers is which of the following?

Arterial insufficiency Explanation: Characteristics of arterial insufficiency ulcers include location at the tips of the toes, extreme painfulness, and circular shape with pale to black ulcer bases. Ulcers caused by venous insufficiency will be irregular in shape, minimal pain if superficial (can be painful), and usually located around the ankles or the anterior tibial area.

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

Avoid constricting garments. Elevate the legs above the heart frequently throughout the day. Sleep with the foot of the bed elevated. Explanation: Elevating the legs decreases edema, promotes venous return, and provides symptomatic relief. The legs should be elevated frequently throughout the day. At night, the patient should sleep with the foot of the bed elevated. Prolonged sitting or standing in one position is detrimental; walking should be encouraged. When sitting, the patient should avoid placing pressure on the popliteal spaces, as occurs when crossing the legs or sitting with the legs dangling over the side of the bed. Constricting garments, especially socks that are too tight at the top or that leave marks on the skin, should be avoided.

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

Constant, intense back pain Decreasing blood pressure Decreasing hematocrit

The nurse is assessing a patient with suspected acute venous insufficiency. What clinical manifestations would indicate this condition to the nurse? (Select all that apply.)

Cool and cyanotic skin Sharp pain that may be relieved by the elevation of the extremity Full superficial veins Explanation: Postthrombotic syndrome is characterized by chronic venous stasis, resulting in edema, altered pigmentation, pain, and stasis dermatitis. The patient may notice the symptoms less in the morning and more in the evening. Obstruction or poor calf muscle pumping in addition to valvular reflux must be present for the development of severe postthrombotic syndrome and stasis ulcers. Superficial veins may be dilated.

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

Dorsiflex the foot while the leg is elevated to check for calf pain. Explanation: Homan's sign is indicated by pain in the calf after the foot is sharply dorsiflexed.

The nurse knows which diagnostic test is used to document the anatomic site of reflux and provides a quantitative measure of the severity of valvular reflux?

Duplex ultrasound scan Explanation: Diagnostic tests for varicose veins include the duplex ultrasound scan, which documents the anatomic site of reflux and provides a quantitative measure of the severity of valvular reflux. Contrast phlebography involves injecting a radiopaque contrast agent into the venous system. Lymphoscintigraphy is done when a radioactively labeled colloid is injected subcutaneously in the second interdigital space. The extremity is then exercised to facilitate the uptake of the colloid by the lymphatic system, and serial images are obtained at preset intervals. Lymphangiography provides a way to detect lymph node involvement resulting from metastatic carcinoma, lymphoma, or infection in sites that are otherwise inaccessible to the examiner except by surgery.

Providing postoperative care to a patient who has percutaneous transluminal angioplasty (PTA), with insertion of a stent, for a femoral artery lesion, includes assessment for the most serious complication of:

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

A patient with diabetes is being treated for a wound on the lower extremity that has been present for 30 days. What option for treatment is available to increase diffusion of oxygen to the hypoxic wound?

Hyperbaric oxygen Explanation: Hyperbaric oxygenation (HBO) may be beneficial as an adjunct treatment in patients with diabetes with no signs of wound healing after 30 days of standard wound treatment. HBO is accomplished by placing the patient into a chamber that increases barometric pressure while the patient is breathing 100% oxygen. Treatment regimens vary from 90 to 120 minutes once daily for 30 to 90 sessions. The process by which HBO is thought to work involves several factors. The edema in the wound area is decreased because high oxygen tension facilitates vasoconstriction and enhances the ability of leukocytes to phagocytize and kill bacteria. In addition, HBO is thought to increase diffusion of oxygen to the hypoxic wound, thereby enhancing epithelial migration and improving collagen production.

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

In 3 to 5 days Explanation: Oral anticoagulants, such as warfarin, are monitored by the PT or the INR. Because the full anticoagulant effect of warfarin is delayed for 3 to 5 days, it is usually administered concurrently with heparin until desired anticoagulation has been achieved (i.e., when the PT is 1.5 to 2 times normal or the INR is 2.0 to 3.0) (Holbrook et al., 2012).

The nurse plans care for a client who is newly diagnosed with peripheral artery disease (PAD).

Increase arterial blood supply to the extremities. Keep legs in a dependent position Increase in physical activity each day. Promote vasodilation and prevent vascular compression Wear warm clothing in the winder Do not use of nicotine products Avoid crossing legs. Explanation: Peripheral artery disease (PAD) is defined as arterial insufficiency of the extremities that occurs most often in men and is a common cause of disability. Appropriate nursing actions to increase arterial blood supply to the client's extremities include keeping the legs in a dependent position and encouraging physical activity. Keeping legs in a dependent position enhances arterial blood supply, while exercise promotes blood flow and the development of collateral circulation. Appropriate nursing actions to promote vasodilation and prevent vascular compression include wearing warm clothing when it is cold, discouraging the use of nicotine products, and advising the client to avoid crossing the legs. Warmth promotes arterial flow by preventing vasoconstriction from chilling; nicotine causes vasospasm, which decreases circulation; and crossing the legs causes compression of vessels with the subsequent impediment of circulation, resulting in venous stasis. Keeping warm, discouraging the use of nicotine products, and telling the client to avoid crossing the legs are nursing actions more appropriate to promote vasodilation and prevent vascular compression versus increasing arterial blood supply to the extremities. Keeping the legs in a dependent position and encouraging physical activity daily are interventions that increase arterial blood supply to the extremities versus promoting vasodilation and preventing vascular compression.

Which sign or symptom suggests that a client's abdominal aortic aneurysm is extending?

Increased abdominal and back pain Explanation: Pain in the abdomen and back signify that the aneurysm is pressing downward on the lumbar nerve root and is causing more pain. The pulse rate would increase with aneurysm extension. Chest pain radiating down the arm would indicate myocardial infarction. Blood pressure would decrease with aneurysm extension, and the respiratory rate may not be affected.

A client is diagnosed with deep vein thrombosis (DVT). Which nursing diagnosis should receive highest priority at this time?

Ineffective peripheral tissue perfusion related to venous congestion Explanation: Ineffective peripheral tissue perfusion related to venous congestion takes highest priority because venous inflammation and clot formation impede blood flow in a client with DVT. Impaired gas exchange related to increased blood flow is incorrect because impaired gas exchange is related to decreased, not increased, blood flow. Excess fluid volume related to peripheral vascular disease is inappropriate because there's no evidence that this client has an excess fluid volume. Risk for injury related to edema may be warranted but is secondary to ineffective tissue perfusion.

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

Intermittent claudication Explanation: The hallmark symptom of PAD in the lower extremity is intermittent claudication. This pain may be described as aching or cramping in a muscle that occurs with the same degree of exercise or activity and is relieved with rest. Acute limb ischemia is a sudden decrease in limb perfusion, which produces new or worsening symptoms that may threaten limb viability. Dizziness and vertigo are associated with upper extremity arterial occlusive disease.

A client is receiving enoxaparin and warfarin therapy for a venous thromboembolism (VTE). Which laboratory value indicates that anticoagulation is adequate and enoxaparin can be discontinued?

International normalized ration (INR) is 2.5. Explanation: Oral anticoagulants such as warfarin are monitored by PT or the INR. Because the full anticoagulant effect of warfarin is delayed for 3 to 5 days, it is usually administered concurrently with heparin until desired anticoagulation has been achieved (i.e., when the PT is 1.5 to 2 times normal or the INR is 2.0 to 3.0)

A home health nurse is teaching a client with peripheral arterial disease ways to improve circulation to the lower extremities. The nurse encourages which of the following in teaching?

Keeping the legs in a neutral or dependent position Explanation: Keeping the legs in a neutral or dependent position assists in delivery of arterial blood from the heart to the lower extremities. All the other choices will aid in venous return, but will hinder arterial supply to the lower extremities.

Which observation regarding ulcer formation on the client's lower extremity indicates to the nurse that the ulcer is a result of venous insufficiency?

Large and superficial Explanation:Ulcerations are in the area of the medial or lateral malleolus (gaiter area) and are typically large, superficial, and highly exudative. Superficial venous insufficiency ulcers cause minimal pain. The base of a venous insufficiency ulcer shows a beefy red to yellow fibrinous color.

Which observation regarding ulcer formation on the client's lower extremity indicates to the nurse that the ulcer is a result of venous insufficiency?

Large and superficial Explanation: Ulcerations are in the area of the medial or lateral malleolus (gaiter area) and are typically large, superficial, and highly exudative. Superficial venous insufficiency ulcers cause minimal pain. The base of a venous insufficiency ulcer shows a beefy red to yellow fibrinous color.

A nurse assesses a patient for a possible abdominal aortic aneurysm (AAA). Which of the following signs would the nurse recognize as positive indicators? Select all that apply.

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

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

Lowering the limb so that it is dependent Explanation: Persistent pain in the forefoot (i.e., the anterior portion of the foot) when the patient is resting indicates a severe degree of arterial insufficiency and a critical state of ischemia. Known as rest pain, this discomfort is often worse at night and may interfere with sleep. This pain frequently requires that the extremity be lowered to a dependent position to improve perfusion to the distal tissues.

Which term refers to enlarged, red, and tender lymph nodes?

Lymphadenitis Explanation: Acute lymphadenitis is demonstrated by enlarged, red, and tender lymph nodes. Lymphangitis is acute inflammation of the lymphatic channels. Lymphedema is demonstrated by swelling of tissues in the extremities because of an increased quantity of lymph that results from an obstruction of lymphatic vessels. Elephantiasis refers to a condition in which chronic swelling of the extremity recedes only slightly with elevation.

Which risk factor is related to venous stasis for deep vein thrombosis (DVT) and pulmonary embolism (PE)?

Obesity Explanation: Obesity is a risk factor for DVT and PE related to venous stasis. Trauma, pacing wires, and surgery are related to endothelial damage as a risk factor for DCAT and PE.

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

Pallor Explanation: Pallor is the initial symptom in Raynaud syndrome followed by cyanosis and aching pain. Gangrene and ulceration can occur with persistent attacks and interference of blood flow.

The most common site of aneurysm formation is in the:

abdominal aorta, just below the renal arteries. Explanation: About 75% of aneurysms occur in the abdominal aorta, just below the renal arteries (Debarked type I aneurysms). Debarked type II aneurysms occur in the aortic arch around the ascending and descending aorta, whereas Debarked type III aneurysms occur in the descending aorta, beyond the subclavian arteries.

While receiving heparin to treat a pulmonary embolus, a client passes bright red urine. What should the nurse do first?

Prepare to administer protamine sulfate. Explanation: Frank hematuria indicates excessive anticoagulation and bleeding — and heparin overdose. The nurse should discontinue the heparin infusion immediately and prepare to administer protamine sulfate, the antidote for heparin. Decreasing the heparin infusion rate wouldn't prevent further bleeding. Although the nurse should continue to monitor PTT, this action should occur later. An I.V. infusion of D5W may be administered, but only after protamine has been given.

A postoperative client is receiving heparin after developing thrombophlebitis. The nurse monitors the client carefully for bleeding and other adverse effects of heparin. If the client starts to exhibit signs of excessive bleeding, the nurse should expect to administer an antidote that is specific to heparin. Which agent fits this description?

Protamine sulfate Explanation: Protamine sulfate is the antidote specific to heparin. Phytonadione (vitamin K) is the antidote specific to oral anticoagulants such as warfarin. (Heparin isn't given orally.) Thrombin is a hemostatic agent used to control local bleeding. Plasma protein fraction, a blood derivative, supplies colloids to the blood and expands plasma volume; it's used to treat clients who are in shock.

A physician orders blood coagulation tests to evaluate a client's blood-clotting ability. The nurse knows that such tests are important in assessing clients at risk for thrombi, such as those with a history of atrial fibrillation, infective endocarditis, prosthetic heart valves, or myocardial infarction. Which test determines a client's response to oral anticoagulant drugs?

Prothrombin time (PT) Explanation: PT determines a client's response to oral anticoagulant therapy. This test measures the time required for a fibrin clot to form in a citrated plasma sample following addition of calcium ions and tissue thromboplastin and compares this time with the fibrin-clotting time in a control sample. The physician should adjust anticoagulant dosages as needed, to maintain PT at 1.5 to 2.5 times the control value. Bleeding time indicates how long it takes for a small puncture wound to stop bleeding. The platelet count reflects the number of circulating platelets in venous or arterial blood. PTT determines the effectiveness of heparin therapy and helps physicians evaluate bleeding tendencies. Physicians diagnose approximately 99% of bleeding disorders on the basis of PT and PTT values.

A client with systemic lupus erythematosus (SLE) complains that his hands become pale, blue, and painful when exposed to the cold. What disease should the nurse cite as an explanation for these signs and symptoms?

Raynaud's disease Explanation: Raynaud's disease results from reduced blood flow to the extremities when exposed to cold or stress. It's commonly associated with connective tissue disorders such as SLE. Signs and symptoms include pallor, coldness, numbness, throbbing pain, and cyanosis. Peripheral vascular disease results from a reduced blood supply to the tissues. It occurs in the arterial or venous system. Build-up of plaque in the vessels or changes in the vessels results in reduced blood flow, causing pain, edema, and hair loss in the affected extremity. Arterial occlusive disease is the obstruction or narrowing of the lumen of the aorta and its major branches that interrupts blood flow to the legs and feet, causing pain and coolness. Buerger's disease is an inflammatory, nonatheromatous occlusive disease that causes segmental lesions and subsequent thrombus formation in arteries, resulting in decreased blood flow to the feet and legs.

A female client is readmitted to the facility with a warm, tender, reddened area on her right calf. Which contributing factor should the nurse recognize as most important?

Recent pelvic surgery Explanation: The client shows signs of deep vein thrombosis (DVT). The pelvic area has a rich blood supply, and thrombophlebitis of the deep veins is associated with pelvic surgery. Aspirin, an antiplatelet agent, and an active walking program help decrease the client's risk of DVT. In general, diabetes mellitus is a contributing factor associated with peripheral vascular disease.

A nurse is admitting a new client with a deep vein thrombosis in her left leg. During the admission process, which information provided by the client would be a contraindication to anticoagulant therapy?

Scheduled eye surgery in 1 week Explanation: Contraindications to anticoagulant therapy include recent or impending eye surgery, recent cerebral vascular bleeds, and recent childbirth. A diet including green leafy vegetables is not a contraindication.

The nurse is caring for a client with abdominal aortic aneurysm (AAA). Which assessment finding is most likely to indicate a dissection of the aneurysm?

Severe pain Explanation: Pressure from an enlarging or dissecting abdominal aortic aneurysm is likely to be exhibited as severe pain. A decrease in blood pressure will result as the client goes into shock from hemorrhaging. Blood in emesis or rectal bleeding is not associated with rupture of AAA.

The nurse is preparing discharge teaching for a client with venous insufficiency. Which information will the nurse include in the instructions? Select all that apply.

Sleep with the foot of the bed elevated 6 inches. Elevate the legs 15 to 20 minutes 4 times a day. Avoid wearing socks that are tight only at the top of the leg. Explanation: Management of the client with venous insufficiency is directed at reducing venous stasis and preventing ulcerations. Discharge teaching should include increasing the time walking because sitting or standing in one position is detrimental. The foot of the bed should be elevated approximately 6 inches to help with venous return. The legs should be elevated for 15 to 20 minutes four times a day to reduce the development of swelling in the legs during the day. Socks that are tight at the top of the leg should not be worn as this can encourage edema and possibly skin breakdown. Graduated compression stockings should be removed during the night and applied in the morning when the amount of blood in the leg veins is at the lowest.

A physician admits a client to the health care facility for treatment of an abdominal aortic aneurysm. When planning this client's care, which goal should the nurse keep in mind as she formulates interventions?

Stabilizing heart rate and blood pressure and easing anxiety Explanation: For a client with an aneurysm, nursing interventions focus on preventing aneurysm rupture by stabilizing heart rate and blood pressure. Easing anxiety also is important because anxiety and increased stimulation may raise the heart rate and boost blood pressure, precipitating aneurysm rupture. The client with an abdominal aortic aneurysm is typically hypertensive, so the nurse should take measures to lower blood pressure, such as administering antihypertensive agents, as ordered, to prevent aneurysm rupture. To sustain major organ perfusion, the client should maintain a mean arterial pressure of at least 60 mm Hg. Although the nurse must assess each client's mobility individually, most clients need bed rest when initially attempting to gain stability.

Which of the following are alterations noted in Virchow's triad? Select all that apply.

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

On a routine visit to the physician, a client with chronic arterial occlusive disease reports that he's stopped smoking after 34 years. To relieve symptoms of intermittent claudication, a condition associated with chronic arterial occlusive disease, which additional measure should the nurse recommend?

Taking daily walks Explanation: Taking daily walks relieves symptoms of intermittent claudication, although the exact mechanism is unclear. Anaerobic exercise may make these symptoms worse. Clients with chronic arterial occlusive disease must reduce daily fat intake to 30% or less of total calories. The client should limit dietary cholesterol because hyperlipidemia is associated with atherosclerosis, a known cause of arterial occlusive disease. However, HDLs have the lowest cholesterol concentration, so this client should eat, not abstain from, foods that raise HDL levels.

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

Teach the client how to apply a graduated compression stocking. Explanation: In severe cases of lymphangitis and lymphadenitis with persistent swelling, the nurse teaches the client how to apply a graduated compression stocking. The nurse informs the physician if the client's temperature remains elevated. The nurse recommends elevating the area to reduce the swelling and provides warmth to promote comfort and to enhance circulation.

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

Teach the client how to apply an elastic sleeve Explanation: In severe cases of lymphangitis and lymphadenitis with persistent swelling, the nurse teaches the client how to apply an elastic sleeve or stocking. The nurse informs the physician if the client's temperature remains elevated. The nurse recommends elevating the area to reduce the swelling and provides warmth to promote comfort and to enhance circulation.

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

The client can walk about 50 feet before getting pain in the right lower leg. Explanation: Intermittent claudication is caused by the inability of the arterial system to provide adequate blood flow to the tissues when increased demands are made for oxygen and nutrients during exercise. Pain is then experienced. When the client rests and decreases demands, the pain subsides. The client can then walk the same distance and repeat the process.

A pregnant client who developed deep vein thrombosis (DVT) in her right leg is receiving heparin I.V. on the medical floor. Physical therapy is ordered to maintain her mobility and prevent additional DVT. A nursing assistant working on the medical unit helps the client with bathing, range-of-motion exercises, and personal care. Which collaborative multidisciplinary considerations should the care plan address?

The client is at risk for heparin-induced thrombocytopenia; therefore, the care plan should include reporting evidence of bleeding or easy bruising. Explanation: Feedback about possible bleeding and bruising from physical therapy and other caregivers should be incorporated into the care plan to ensure safety and optimal outcomes. Using a sequential compression device, mandating strict bed rest, and reporting signs of DVT don't incorporate collaborative care. Reporting signs of premature labor doesn't address the consequences of thrombocytopenia, which may occur with I.V. heparin therapy.

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

Ulceration Explanation: Venous ulceration is the most serious complication of chronic venous insufficiency and can be associated with other conditions affecting the circulation of the lower extremities. Cellulitis or dermatitis may complicate the care of chronic venous insufficiency and venous ulcerations.

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

Ulcers and infection in the edematous area Explanation: In a client with lymphedema, the tissue nutrition is impaired as a result of the stagnation of lymphatic fluid, leading to ulcers and infection in the edematous area. Later, the skin also appears thickened, rough, and discolored. Scaring does not occur in clients with lymphedema. Cyanosis is a bluish discoloration of the skin and mucous membranes.

The nurse is caring for a client who is scheduled to have a vein ligation in the morning. How would you describe a vein ligation to the client?

Veins are tied off and left in the leg. Explanation: A vein ligation is a procedure in which the affected veins are ligated (tied off) above and below the area of incompetent valves, but the dysfunctional vein remains. A vein stripping is the removal of the veins after being tied off.

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

Venous insufficiency Explanation: Symptoms of venous insufficiency include present pedal pulses, edema, pigmentation in gaiter area, and a reddish blue color. Ulcers caused by venous insufficiency will be irregular in shape and usually located around the ankles or the anterior tibial area. Characteristics of arterial insufficiency ulcers include location at the tips of the toes, great pain, and circular shape with a pale to black ulcer base.

The nurse is preparing a teaching tool about the development of a venous thromboembolism. Which information about Virchow triad will the nurse include? Select all that apply.

Venous stasis Endothelial damage Altered coagulation Explanation: Although the exact cause of venous thromboemboli are unclear, three factors known as Virchow triad are believed to play a role in the development. These factors include venous stasis, endothelial damage, and altered coagulation. Prominent veins and edema of the affected extremity are symptoms associated with deep vein thrombosis.

The nurse is caring for a client who is known to have a high risk for venous thromboembolism. What preventive actions should the nurse recommend? Select all that apply.

Weight loss Regular exercise Smoking cessation Explanation: Clients at risk for VTE should be advised to make lifestyle changes, as appropriate, which may include weight loss, smoking cessation, and regular exercise. Increased protein intake and supplementation with vitamin D and calcium do not address the main risk factors for VTE.

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

ankle-brachial index Explanation: The client's symptoms indicate possible peripheral artery disease (PAD). The ankle-brachial index is a simple, noninvasive test used for this diagnosis. An exercise electrocardiography may be ordered for a client with possible CAD. An EBCT is a radiologic test that produces x-rays of the coronary arteries using an electron beam. It is used to diagnose for CAD. Clients with suspected venous insufficiency will undergo photoplethysmography, a diagnostic test that measures light that is not absorbed by hemoglobin and consequently is reflected back to the machine.

A client with no known history of peripheral vascular disease comes to the emergency department complaining of sudden onset of lower leg pain. Inspection and palpation reveal absent pulses; paresthesia; and a mottled, cyanotic, cold, and cadaverous left calf. While the physician determines the appropriate therapy, the nurse should:

keep the affected leg level or slightly dependent. Explanation: While the physician makes treatment decisions, the nurse should maintain the client on bed rest, keeping the affected leg level or slightly dependent (to aid circulation) and protecting it from pressure and other trauma. Warming the leg with a heating pad (or chilling it with an ice pack) would further compromise tissue perfusion and increase injury to the leg. Elevating the leg would worsen tissue ischemia. Shaving an ischemic leg could cause accidental trauma from cuts or nicks.

The term for a diagnostic test that involves injection of a contrast media into the venous system through a dorsal vein in the foot is

contrast phlebography. Explanation: When a thrombus exists, an x-ray image will disclose an unfilled segment of a vein. Air plethysmography quantifies venous reflux and calf muscle pump ejection. In lymphangiography, contrast media are injected into the lymph system. In a lymphoscintigraphy, a radioactive-labeled colloid is injected into the lymph system.

Vasodilation or vasoconstriction produced by an external cause will interfere with a nurse's accurate assessment of a client with peripheral vascular disease (PVD). Therefore, the nurse should:

keep the client warm. Explanation: The nurse should keep the client covered and expose only the portion of the client's body that she's assessing. The nurse should also keep the client warm by maintaining his room temperature between 68° F and 74° F (20° and 23.3° C). Extreme temperatures aren't good for clients with PVD. The valves in their arteries and veins are already insufficient, and exposing them to vast changes in temperature could affect assessment findings. Keeping the client uncovered would cause him to become chilled. Matching the room temperature to the client's body temperature is inappropriate.