Chapter 30: Assessment and Management of Patients With Vascular Disorders and Problems of Peripheral Circulation
The nurse is assessing a client with severe hypertension. Which symptom indicates to the nurse that the client is experiencing dissection of the aorta? Numbness and pain of the left arm Pain when flexing the neck forward Gradual onset of a frontal headache A ripping sensation in the chest
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.
To assess the dorsalis pedis artery, the nurse would use the tips of three fingers and apply light pressure to the: Inside of the ankle just above the heel. Exterior surface of the foot near the heel. Outside of the foot just below the heel. Anterior surface of the foot near the ankle joint.
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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 30: Assessment and Management of Patients With Vascular Disorders and Problems of Peripheral Circulation, Figure 30-2, p. 846. Chapter 30: Assessment and Management of Patients With Vascular Disorders and Problems of Peripheral Circulation - Page 846
A client is recovering from surgical repair of a dissecting aortic aneurysm. Which assessment findings indicate possible bleeding or recurring dissection? Urine output of 15 ml/hour and 2+ hematuria Blood pressure of 82/40 mm Hg and heart rate of 125 beats/minute Urine output of 150 ml/hour and heart rate of 45 beats/minute Blood pressure of 82/40 mm Hg and heart rate of 45 beats/minute
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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 30: Assessment and Management of Patients With Vascular Disorders and Problems of Peripheral Circulation, Dissecting Aorta, p. 865.
Which of the following is a characteristic of an arterial ulcer? Border regular and well demarcated Brawny edema Ankle-brachial index (ABI) > 0.90 Edema may be severe
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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 30: Assessment and Management of Patients With Vascular Disorders and Problems of Peripheral Circulation, Arterial Ulcers, p. 875.
Which of the following are indications of a rupturing aortic aneurysm? Select all that apply. Constant, intense back pain Decreasing blood pressure Decreasing hematocrit Increasing blood pressure Increasing hematocrit
Constant, intense back pain Decreasing blood pressure Decreasing hematocrit Explanation: Indications of a rupturing abdominal aneurysm include constant, intense back pain; falling blood pressure; and decreasing hematocrit. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 30: Assessment and Management of Patients With Vascular Disorders and Problems of Peripheral Circulation, Clinical Manifestations, p. 863.
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 Constant, intense headache and falling blood pressure Higher than normal blood pressure and falling hematocrit Slow heart rate and high blood pressure
Constant, intense back pain and falling blood pressure Explanation: Indications of a rupturing abdominal aortic aneurysm include constant, intense back pain; falling blood pressure; and decreasing hematocrit. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 30: Assessment and Management of Patients With Vascular Disorders and Problems of Peripheral Circulation, p. 863.
Which is a characteristic of arterial insufficiency? Diminished or absent pulses Superficial ulcer Aching, cramping pain Pulses are present but may be difficult to palpate
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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 30: Assessment and Management of Patients With Vascular Disorders and Problems of Peripheral Circulation, Table 30-1, p. 845.
Which aneurysm results in bleeding into the layers of the arterial wall? Saccular Dissecting False Anastomotic
Dissecting Explanation: Dissection results from a rupture in the intimal layer, resulting in bleeding between the intimal and medial layers of the arterial wall. Saccular aneurysms collect blood in the weakened outpouching. In a false aneurysm, the mass is actually a pulsating hematoma. An anastomotic aneurysm occurs as a result of infection at arterial suture or graft sites. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 30: Assessment and Management of Patients With Vascular Disorders and Problems of Peripheral Circulation, Figure 30-11, p. 862.
Which sign or symptom suggests that a client's abdominal aortic aneurysm is extending? Increased abdominal and back pain Decreased pulse rate and blood pressure Retrosternal back pain radiating to the left arm Elevated blood pressure and rapid respirations
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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 30: Assessment and Management of Patients With Vascular Disorders and Problems of Peripheral Circulation, Pathophysiology, p. 863.
Aortic dissection may be mistaken for which of the following disease processes? Myocardial infarction (MI) Stroke Pneumothorax Angina
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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 30: Assessment and Management of Patients With Vascular Disorders and Problems of Peripheral Circulation, Clinical Manifestations, p. 865.
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 Hematemesis Rectal bleeding Hypertensive crisis
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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 30: Assessment and Management of Patients With Vascular Disorders and Problems of Peripheral Circulation, Clinical Manifestations, p. 863.
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? Decreasing blood pressure and increasing mobility Increasing blood pressure and reducing mobility Stabilizing heart rate and blood pressure and easing anxiety Increasing blood pressure and monitoring fluid intake and output
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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 30: Assessment and Management of Patients With Vascular Disorders and Problems of Peripheral Circulation, Medical Management, p. 864.
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 Reduced radial pulses Aphonia
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 has become obstructed. The aneurysm may be preparing to rupture. The client is experiencing inflammation of the aneurysm. The client is experiencing normal sensations associated with this condition.
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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 30: Assessment and Management of Patients With Vascular Disorders and Problems of Peripheral Circulation, p. 863.
Which of the following is the most common site for a dissecting aneurysm? Thoracic area Lumbar area Sacral area Cervical area
Thoracic area Explanation: The thoracic area is the most common site for a dissecting aneurysm. About one-third of patients with thoracic aneurysms die of rupture of the aneurysm. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 30: Assessment and Management of Patients With Vascular Disorders and Problems of Peripheral Circulation, Thoracic Aortic Aneurysm, p. 862.
The most common site of aneurysm formation is in the: abdominal aorta, just below the renal arteries. ascending aorta, around the aortic arch. descending aorta, beyond the subclavian arteries. aortic arch, around the ascending and descending aorta.
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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 30: Assessment and Management of Patients With Vascular Disorders and Problems of Peripheral Circulation, Aneurysms, p. 862.
