Hinkle Ch 26: Assessment and Management of Vascular and Peripheral Circulation Disorders
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) Platelet count Partial thromboplastin time (PTT) Bleeding time
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.
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 Offer cold applications to promote comfort and to enhance circulation Inform the physician if the client's temperature remains low Avoid elevating the area
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 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. The aneurysm has become obstructed. 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.
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? 0.10 0.50 0.35 0.25
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.
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. Expect a burning sensation in the injected areas for 1 to 2 days. Wear graduated compression stockings for a week after the procedure. Increase the amount of time walking at home. Take acetaminophen as prescribed for pain. Change the dressings once a day.
1- Increase # time walking at home 2- Take APAP as prescribed for pain 3- Expect a burning sensation in the injected areas for 1-2 d 4- Wear graduated compression stockings for 1 week after.
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 Decreased bowel sounds Lower abdominal pain Low back pain Diarrhea
1- Pulsatile Abdominal mass 2- Lower Back Pain 3- Lower Abdominal Pain
Which of the following are alterations noted in Virchow's triad? Select all that apply. Edema Tenderness Altered coagulation Vessel wall injury Stasis of blood
1- Stasis of Blood 2- Vessel Wall Injury 3- Altered Coagulation
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. 4.5 times the baseline control. 3.5 times the baseline control. 2.5 to 3.0 times the baseline control.
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? 20 30 40 50
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? 20 30 40 50
50 Explanation: Typically, about 50% of the arterial lumen or 75% of the cross-sectional area must be obstructed before intermittent claudication is experienced.
The nurse is assessing a client with severe hypertension. Which symptom indicates to the nurse that the client is experiencing dissection of the aorta? Pain when flexing the neck forward Gradual onset of a frontal headache Numbness and pain of the left arm 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.
Which of the following medications is considered a thrombolytic? Coumadin Alteplase Heparin Lovenox
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.
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: Urokinase. Streptokinase Alteplase. Reteplase.
Alteplase. Explanation: Alteplase has fewer disadvantages than the other thrombolytic agents. Refer to Table 18-2 in the text.
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 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? Venous insufficiency Arterial insufficiency Trauma Neither venous nor arterial
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.
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. Ask about any changes in skin color that occur in response to cold. Assess for unilateral swelling and tenderness of either leg. Check for the presence of tortuous veins bilaterally on the legs.
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.
Which observation regarding ulcer formation on the client's lower extremity indicates that the ulcer is a result of venous insufficiency? Though superficial, it is very painful Is deep, involving the joint space Base is pale to black Border of the ulcer is irregular
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 Ankle-brachial index (ABI) > 0.90 Edema may be severe Brawny edema
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.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.
Pentoxifylline (Trental) is a medication used for which of the following conditions? Claudication Elevated triglycerides Hypertension Thromboemboli
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.
The nurse assesses a patient with hip pain related to intermittent claudication. She knows that the area of arterial narrowing is the: Anterior tibial. Posterior tibial. Common iliac artery. Common femoral artery.
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? Aspirin therapy Physical therapy Compression sleeve Arm sling
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.
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? Magnetic resonance angiography (MRA) Angiography Doppler ultrasound Computed tomography angiography (CTA)
Computed tomography angiography (CTA) Explanation: A CTA is used to visualize arteries and veins and help assess for stenosis and occlusion.
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 headache and falling blood pressure Constant, intense back pain 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.
Which is a characteristic of arterial insufficiency? Pulses are present but may be difficult to palpate Diminished or absent pulses Superficial ulcer Aching, cramping pain
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.
Which aneurysm results in bleeding into the layers of the arterial wall? False Saccular Anastomotic Dissecting
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 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? Elevate LE's for 20min & then lower slowly - assess blood return Dorsiflex the foot while the leg is elevated to check for calf pain. Lower LE's and massage the calf muscles to note any areas of tenderness. Extend leg, plantar flex foot, and check patency of dorsalis pedis pulse.
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.
Which class of medication lyses and dissolves thrombi? Platelet inhibitors Anticoagulant Fibrinolytic Factor XA inhibitors
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.
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: Thrombosis of the graft. Hemorrhage. Stent dislodgement. Decreased motor function.
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 Enzymatic debridement Vacuum-assisted closure device Surgical debridement
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 plans care for a client who is newly diagnosed with peripheral artery disease (PAD). For each nsg action, click to specify if the intervention is appropriate to increase the arterial blood supply to the client's extremities or to promote vasodilation and prevent vascular compression. Avoid crossing the legs. Increase in physical activity each day. Do not use of bicotine products. Wear warm clothing in the winter. Keep legs in a dependent position.
Increase Arterial Blood Supply to Extremities: 1- Keep LE's in dependent position 2- Increase in physical activity every day Promote Vasodilation & Prevent Vascular Compression: 1- Wear warm clothing in winter 2- Do not use Bicotine products 3- Avoid crossing the LE's
Which sign or symptom suggests that a client's abdominal aortic aneurysm is extending? Decreased pulse rate and blood pressure Increased abdominal and back pain 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.
Which of the following is the hallmark symptom for peripheral arterial disease (PAD) in the lower extremity? Vertigo Dizziness Acute limb ischemia Intermittent claudication
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 ratio (INR) is 2.5. Prothrombin time (PT) is 0.5 times normal. K+ level is 3.5. Activated partial thromboplastin time (aPPT) is half of the control value
International normalized ratio (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? Elevation of the legs above the heart Use of antiembolic stockings Application of ace wraps from the toe to below the knees Keeping the legs in a neutral or dependent position
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 term refers to enlarged, red, and tender lymph nodes? Lymphedema Lymphadenitis Elephantiasis Lymphangitis
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 No arterial insufficiency Tissue loss to that foot Very mild arterial insufficiency
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.
Aortic dissection may be mistaken for which of the following disease processes? Angina Myocardial infarction (MI) Stroke Pneumothorax
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.
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? Within 12 hours In 3 to 5 days In 2 days Within the first 24 hours
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).
A nurse is caring for a client following an arterial vascular bypass graft in the leg. What should the nurse plan to assess over the next 24 hours? Color of the leg every 4 hours Ankle-arm indices every 12 hours Blood pressure every 2 hours Peripheral pulses every 15 minutes after surgery
Peripheral pulses every 15 minutes after surgery Explanation: The primary objective in the postoperative period is to maintain adequate circulation through the arterial repair. Pulses, Doppler assessment, color and temperature, capillary refill, and sensory and motor function of the affected extremity are checked and compared with those of the other extremity; these values are recorded initially every 15 minutes and then at progressively longer intervals if the client's status remains stable.
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. Common femoral. Popliteal. Internal iliac.
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.
While receiving heparin to treat a pulmonary embolus, a client passes bright red urine. What should the nurse do first? Monitor the partial thromboplastin time (PTT). Decrease the heparin infusion rate. Start an I.V. infusion of dextrose 5% in water (D5W). Prepare to administer protamine sulfate.
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 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." "It is better to soak your feet in hot water as long as the water temperature is below 110 degrees F." "A heating pad to your feet is fine as long as the temperature stays below 105 degrees F." "A heating pad to your feet is a good idea because it increases the metabolic rate."
"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." "I can use lamb's wool between my toes if necessary." "It is important to apply sunscreen to the top of my feet when wearing sandals." "I should apply powder daily because my feet perspire."
"Shoes made of synthetic material are best for my feet."
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. The client is pregnant and receiving I.V. heparin, placing her at risk for premature labor; therefore, the care plan should include reporting signs of premature labor. The client is at risk for heparin-induced thrombocytopenia; therefore, the care plan should include sequential compression device application and strict bed rest. The client is at risk for developing another DVT; therefore, the care plan should include reporting redness, tenderness, or edema in the other lower extremity.
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 most important factor regulating the caliber of blood vessels, which determines resistance to flow, is: Independent arterial wall activity. The influence of circulating chemicals. Hormonal secretion. The sympathetic nervous system.
The sympathetic nervous system. Explanation:v Stimulation of the sympathetic nervous system causes vasoconstriction thus regulating blood flow. Norepinephrine is the responsible neurotransmitter.
Which of the following is the most common site for a dissecting aneurysm? Thoracic area Sacral area Cervical area Lumbar 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.
What symptoms should the nurse assess for in a client with lymphedema as a result of impaired nutrition to the tissue? Evident scaring Ulcers and infection in the edematous area Cyanosis Loose and wrinkled skin
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? Removal of the great saphenous vein. Veins are tied off and left in the leg. Removal of the small saphenous vein. Veins are tied off and removed.
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 knows which diagnostic test is used to document the anatomic site of reflux and provides a quantitative measure of the severity of valvular reflux? Contrast phlebography Lymphangiography Duplex ultrasound scan Lymphoscintigraphy
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.
Which client with a venous stasis ulcer is a candidate for topical hyperbaric oxygen therapy? a nonambulatory client a client with a chronic, nonhealing skin lesion a client with an infected stasis ulcer a client whose ulcer includes necrotic tissue
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.
The most common site of aneurysm formation is in the: descending aorta, beyond the subclavian arteries. ascending aorta, around the aortic arch. aortic arch, around the ascending and descending aorta. abdominal aorta, just below the renal arteries.
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.
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? photoplethysmography exercise electrocardiography ankle-brachial index electron beam computed tomography
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.
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. lymphoscintigraphy. lymphangiography. air plethysmography.
contrast phlebography. Explanation: Also known as venography, contrast phlebography involves injecting a radiopaque contrast agent into the venous system. If a thrombus exists, the x-ray image reveals an unfilled segment of vein in an otherwise completely filled 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.
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. no rubor for 10 seconds after the maneuver. a 30-second filling time for the veins. elevational rubor.
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.
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. a decrease in the left pedal pulse. pallor and coolness of the left foot. loss of hair on the lower portion of the left leg.
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.
