Chapter 30

A community health nurse teaches a group of seniors about modifiable risk factors that contribute to the development of peripheral arterial disease (PAD). The nurse knows that the teaching was effective based on which of the following statements?

"I will need to stop smoking because the nicotine causes less blood to flow to my hands and feet."

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

"The Lovenox will work immediately, but the Coumadin takes several days to reach its full effect."

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

"Walk to the point of pain, rest until the pain subsides, then resume ambulation."

The 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

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.

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

Anterior surface of the foot near the ankle joint.

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

Application of graduated compression stockings

You are presenting a workshop at the senior citizens center about how the changes of aging predisposes clients to vascular occlusive disorders. What would you name as the most common cause of peripheral arterial problems in the older adult?

Atherosclerosis

The nurse is 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 cause ischemic episodes

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

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

Border regular and well demarcated

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

Claudication

A client is hospitalized for repair of an abdominal aortic aneurysm. The nurse must be alert for signs and symptoms of aneurysm rupture and thus looks for which of the following?

Constant, intense back pain and falling blood pressure

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 which of the following?

Contrast phlebography

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

As the clinic nurse caring for a client with varicose veins, what is an appropriate nursing action for this client?

Demonstrate how to apply and remove elastic support stockings.

The nurse performing an assessment on a patient who has arterial insufficiency of the legs and an ulcer on the left great toe would expect to find which of the following characteristics?

Diminished or absent pulses

Which of the following are characteristics of arterial insufficiency?

Diminished or absent pulses

Which of the following aneurysms results in bleeding into the layers of the arterial wall?

Dissecting

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

Duplex ultrasound scan

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

Which of the following statements is accurate regarding Reynaud's disease?

Episodes may be triggered by unusual sensitivity to cold.

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

A client who underwent total hip replacement exhibits a red, painful area on the calf of the affected leg. What test validates presence of thromboembolism?

Homan's

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

Increased abdominal and back pain

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

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

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

Myocardial infarction (MI)

Which of the following are risk factors for venous disorders of the lower extremities?

Obesity

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

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)

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

Raynaud's disease

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

Recent pelvic surgery

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

Stabilizing heart rate and blood pressure and easing anxiety

A nurse is providing education about the prevention of arterial constriction to a client with peripheral arterial disease. Which of the following includes priority information the nurse would give to the client?

Stop smoking

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

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

Teach the patient how to apply a graduated compression stocking.

A nurse and physician are preparing to visit a hospitalized client with perepheral 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.

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

Ulceration

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

Ulcers and infection in the edematous area

The nurse teaches the patient with peripheral vascular disease (PVD) to refrain from smoking because nicotine causes which of the following?

Vasospasm

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

Venous insufficiency

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

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

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