CH 26 Assessment and Management of Patients with Vascular Disorders and Disorders of Peripheral Circulation

Heparin therapy is usually considered therapeutic when the activated partial thromboplastin time (aPTT) is how many times higher than a normal value? 0.5 to 1.5 1.5 to 2.5 2.5 to 3.5 3.5 to 4.5

1.5 to 2.5

To assess the dorsalis pedis artery, the nurse would use the tips of three fingers and apply light pressure to the: Outside of the foot just below the heel. Anterior surface of the foot near the ankle joint. Inside of the ankle just above the heel. Exterior surface of the foot near the heel.

Anterior surface of the foot near the ankle joint.

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? Aneurysm Coronary thrombosis Atherosclerosis Raynaud's disease

Atherosclerosis

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: Obesity. Cigarette smoking. Lack of exercise. Stress.

Cigarette smoking.

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 Slow heart rate and high blood pressure Constant, intense headache and falling blood pressure Higher than normal blood pressure and falling hematocrit

Constant, intense back pain and falling blood pressure

As the clinic nurse caring for a client with varicose veins, what is an appropriate nursing action for this client? Assess for skin integrity. Demonstrate how to self-administer IV infusions. Assess for the sites of bleeding. Demonstrate how to apply and remove elastic support stockings.

Demonstrate how to apply and remove elastic support stockings.

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 the patient's legs for 20 minutes and then lower them slowly while checking for areas of inadequate blood return. Lower the patient's legs and massage the calf muscles to note any areas of tenderness. Extend the leg, plantar flex the foot, and check for the patency of the dorsalis pedis pulse. Dorsiflex the foot while the leg is elevated to check for calf pain.

Dorsiflex the foot while the leg is elevated to check for calf pain.

The nurse is educating a patient 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.) Elevate the legs above the heart level for 30 minutes every 2 hours. Avoid constricting garments. Sleep with the foot of the bed elevated about 6 inches. Sit as much as possible to rest the valves in the legs. Sit on the side of the bed and dangle the feet.

Elevate the legs above the heart level for 30 minutes every 2 hours. Avoid constricting garments. Sleep with the foot of the bed elevated about 6 inches.

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 Surgical debridement Vacuum-assisted closure device

Hyperbaric oxygen

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 2 days Within the first 24 hours In 3 to 5 days

In 3 to 5 days

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 Risk for injury related to edema Excess fluid volume related to peripheral vascular disease Impaired gas exchange related to increased blood flow

Ineffective peripheral tissue perfusion related to venous congestion

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? Activated partial thromboplastin time (aPPT) is half of the control value K+ level is 3.5. Prothrombin time (PT) is 0.5 times normal. International normalized ratio (INR) is 2.5.

International normalized ratio (INR) is 2.5.

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? Very mild arterial insufficiency No arterial insufficiency Moderate to severe arterial insufficiency Tissue loss to that foot

Moderate to severe arterial insufficiency

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? Gangrene Pallor Ulceration Cyanosis

Pallor

A client has been diagnosed with peripheral arterial occlusive disease. Which of the following instructions is appropriate for the nurse to give the client for promoting circulation to the extremities? Use a heating pad to promote warmth. Keep the extremities elevated slightly. Participate in a regular walking program. Massage the calf muscles if pain occurs.

Participate in a regular walking program.

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 Blood pressure every 2 hours Peripheral pulses every 15 minutes after surgery Ankle-arm indices every 12 hours

Peripheral pulses every 15 minutes after surgery

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 Thrombin Phytonadione (vitamin K) Plasma protein fraction

Protamine sulfate

What should the nurse do to manage the persistent swelling in a client with severe lymphangitis and lymphadenitis? Inform the physician if the client's temperature remains low Teach the client how to apply an elastic sleeve Offer cold applications to promote comfort and to enhance circulation Avoid elevating the area

Teach the client how to apply an elastic sleeve

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? Arterial occlusive diseases Raynaud's disease Peripheral vascular disease Buerger's disease

Raynaud's disease

Which of the following is the most effective intervention for preventing progression of vascular disease? Avoid trauma Use neutral soaps Wear sturdy shoes Risk factor modification

Risk factor modification

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? Reducing daily fat intake to less than 45% of total calories Abstaining from foods that increase levels of high-density lipoproteins (HDLs) Taking daily walks Engaging in anaerobic exercise

Taking daily walks

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's legs awaken him during the night with itching. The client experiences shortness of breath after walking about 50 feet. The client's fingers tingle when left in one position for too long. The client can walk about 50 feet before getting pain in the right lower leg.

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. For what should the nurse assess the patient's lower extremities? Dermatitis Ulceration Rubor Cellulitis

Ulceration

What symptoms should the nurse assess for in a client with lymphedema as a result of impaired nutrition to the tissue? Cyanosis Ulcers and infection in the edematous area Loose and wrinkled skin Evident scarring

Ulcers and infection in the edematous area

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 lymphoscintigraphy. air plethysmography. contrast phlebography. lymphangiography.

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: increases high-density lipoprotein (HDL) level. decreases venous congestion. reduces stress. aids in weight reduction.

decreases venous congestion.

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: no rubor for 10 seconds after the maneuver. elevational rubor. elevational pallor. a 30-second filling time for the veins.

elevational pallor.

A nurse is instructing a client about using antiembolism stockings. Antiembolism stockings help prevent deep vein thrombosis (DVT) by: elevating the extremity to prevent pooling of blood. providing warmth to the extremity. encouraging ambulation to prevent pooling of blood. forcing blood into the deep venous system.

forcing blood into the deep venous system.