Honan Nursing management: Patients with vascular disorders and problems with peripheral circulation ch 17

A nurse is reviewing self-care measures for a client with peripheral vascular disease. Which statement indicates proper self-care measures? "I like to soak my feet in the hot tub every day." "I walk only to the mailbox in my bare feet." "I stopped smoking and use only chewing tobacco." "I have my wife look at the soles of my feet each day."

"I have my wife look at the soles of my feet each day."

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." "It is important to apply sunscreen to the top of my feet when wearing sandals." "I should apply powder daily because my feet perspire." "I can use lamb's wool between my toes if necessary."

"Shoes made of synthetic material are best for my feet."

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? "Administration of two anticoagulants decreases the risk of recurrent venous thrombosis." "Enoxaparin will dissolve the clot, and warfarin will prevent any more clots from occurring." "The enoxaparin will work immediately, but the warfarin takes several days to achieve its full effect." "Because of the potential for a pulmonary embolism, it is important for you to take at least two anticoagulants."

"The enoxaparin will work immediately, but the warfarin takes several days to achieve its full effect."

Following abdominal surgery, which factor predisposes a client to deep vein thrombosis? The client is 5' 9" tall and weighs 128 lb (58 kg). The client has been pregnant four times. The client usually walks 3 miles a day. The client will be immobile during and shortly after surgery.

The client will be immobile during and shortly after surgery.

A nurse in a long-term care facility is caring for an 83-year-old client who has a history of heart failure (HF) and peripheral arterial disease (PAD). At present, the client is unable to stand or ambulate. The nurse should implement measures to prevent which complication? Aortitis Deep vein thrombosis Thoracic aortic aneurysm Raynaud disease

DVT three factors, known as Virchow triad, are believed to play a significant role in its development: stasis of blood (venous stasis) vessel wall injury altered blood 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. 2.5 to 3.0 times the baseline control. 3.5 times the baseline control. 4.5 times the baseline control.

1.5 to 2.5 times the baseline control.

A patient who developed a deep vein thrombosis (DVT) is being treated with unfractionated heparin. The hospital's protocol for this treatment specifies analysis of the patient's activated partial thromboplastin time (aPTT) every 6 hours. When reviewing the patient's aPTT levels, the nurse should be aware that the desired levels for this patient will be: 60% to 70% of the normal reference range Slightly below or equal to the normal reference range Within normal reference range 1.5 to 2.5 times the normal reference range

1.5 to 2.5 times the normal reference range

Nursing management of a patient receiving heparin includes monitoring for heparin-induced thrombocytopenia. Choose the result that indicates the potential for spontaneous intracranial hemorrhage, which is life-threatening. A platelet count of: 90,000 to 150,000 mm3 50,000 to 80,000 mm3 20,000 to 40,000 mm3 10,000 to 14,500 mm3

10,000 to 14,500 mm3

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

Approximately what percentage of the arterial lumen must be obstructed before intermittent claudication is experienced? 20 30 40 50

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

A medical nurse has admitted four clients over the course of a 12-hour shift. For which client would assessment of ankle-brachial index (ABI) be most clearly warranted? A client who has peripheral edema secondary to chronic heart failure An older adult client who has a diagnosis of unstable angina A client with poorly controlled type 1 diabetes who is a smoker A client who has community-acquired pneumonia and a history of COPD

A client with poorly controlled type 1 diabetes who is a smoker

An older adult client has been treated for a venous ulcer and a plan is in place to prevent the occurrence of future ulcers. What should the nurse include in this plan? Use of supplementary oxygen to aid tissue oxygenation Daily use of normal saline compresses on the lower limbs Daily administration of prophylactic antibiotics A high-protein diet that is rich in vitamins

A high-protein diet that is rich in vitamins

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

You are assessing a client recently admitted to your unit for hypotension. While assessing this client, you find a pulsatile mass near the umbilicus. What would you suspect? Coronary artery disease Aortic aneurysm Raynaud's disease Peripheral artery disease

Aortic aneurysm

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? Report changes in the usual pattern of chest pain. Avoid situations that contribute to ischemic episodes. Avoid fatty foods and exercise. Take over-the-counter decongestants.

Avoid situations that contribute to ischemic episodes. 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. the nurse advises clients to avoid over-the-counter decongestants (because the constrict blood vessels)

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. Reteplase. Urokinase. Streptokinase

Alteplase.

The nurse is preparing a teaching plan for a patient with venous insufficiency and plans to address measures to prevent complications from venous insufficiency. What is one measure the nurse should include in the plan? Avoiding tight-fitting socks Reducing activity Sleeping with legs dependent Avoiding pressure stockings

Avoiding tight-fitting socks

The nurse explains to a patient that the primary cause of a varicose vein is: Phlebothrombosis. An incompetent venous valve. Venospasm. Venous occlusion.

An incompetent venous valve.

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. press lightly, especially if patient has PAD

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? Adequate carbohydrate intake Application of graduated compression stockings Prophylactic antibiotic therapy Methods of keeping the wound area dry

Application of graduated compression stockings

A patient with a diagnosis of deep vein thrombosis (DVT) is being treated with unfractionated heparin, which is being administered intravenously. The nurse who is providing care for this patient should consequently prioritize what assessments? Assessing the patient for internal or external hemorrhage Monitoring the patient's intake and output, and assessing for signs of fluid volume deficit Assessing the patient for adventitious lung sounds and assessing SaO2 levels Assessing the patient's pain levels

Assessing the patient for internal or external hemorrhage IV heparin administration creates a significant risk of bleeding.

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? Check for the presence of tortuous veins bilaterally on the legs. Ask about any changes in skin color that occur in response to cold. Attempt to palpate the dorsalis pedis and posterior tibial pulses. Assess for unilateral swelling and tenderness of either leg.

Attempt to palpate the dorsalis pedis and posterior tibial pulses.

The nurse is educating a client with chronic venous insufficiency about the prevention of complications related to the disorder. What should the nurse include in the information given to the client? Select all that apply. Avoid constricting garments. Elevate the legs above the heart frequently throughout the day. Sit as much as possible to rest the valves in the legs. Sleep with the foot of the bed elevated. Sit on the side of the bed and dangle the feet.

Avoid constricting garments. Elevate the legs above the heart frequently throughout the day. Sleep with the foot of the bed elevated.

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 compensation mechanism 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.

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 Though superficial, it is very painful Base is pale to black Is deep, involving the joint space

Border of the ulcer is irregular

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

When it is determined that the muscle fibers and endothelial lining of the walls of their small arteries and arterioles have become inflamed, the patient will be evaluated for what possible disease process?

Buerger Buerger disease is characterized by recurring inflammation of the intermediate and small arteries and veins, resulting in thrombus formation and vessel occlusion. Primary Raynaud disease (primary Raynaud phenomenon or idiopathic Raynaud phenomenon) refers to vasospasm that occurs with cold or stress. An aneurysm is a localized outpouching, sac, or dilation formed at a weak point in the artery wall. Intermittent claudication causes pain that 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. Intermittent claudication is caused by the inability of the arterial system to provide adequate blood flow to the tissues in the face of increased demand for nutrients and oxygen during exercise.

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. Lack of exercise. Obesity. Stress.

Cigarette smoking.

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. Common femoral artery. Anterior tibial. Posterior tibial.

Common iliac artery.

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? Doppler ultrasound Magnetic resonance angiography (MRA) Angiography Computed tomography angiography (CTA)

Computed tomography angiography (CTA)

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

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

A woman has sought care from her nurse practitioner for the treatment of a wound on her lower leg that has been slow to heal. When planning this patient's care, what action should the nurse first perform? -Cleanse the wound bed with normal saline and apply a hydrocolloid dressing. -Take a culture and sensitivity swab from the wound bed. -Determine whether the ulcer results from arterial insufficiency or venous insufficiency. -Prescribe the woman a course of broad-spectrum antibiotics.

Determine whether the ulcer results from arterial insufficiency or venous insufficiency.

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 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? Saccular Dissecting False Anastomotic

Dissecting

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

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

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 an hour. Avoid foods with iodine. Elevate the legs periodically for at least 15 to 20 minutes. Refrain from sexual activity for a week.

Elevate the legs periodically for at least 15 to 20 minutes.

When caring for a patient with leg ulcers, the positioning of the legs depends on whether the patient's ulcer is arterial or venous in origin. How should the nurse position a patient who has leg ulcers that are venous in origin? Keep the patient's legs flat without the knees raised. Keep the patient's knees at a 45-degree angle. Elevate the patient's lower extremities. Hang the patient's legs over the side of the bed

Elevate the patient's lower extremities. Bending the knees, keeping the legs flat, and dangling the patient's legs may exacerbate the condition.

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? Sleep with the legs in a horizontal position. Engage in an unsupervised walking program. Take an aspirin before going to bed at night. Elevate the lower extremities several times during the day.

Engage in an unsupervised walking program. 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.

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? Metoprolol (Lopressor) Epinephrine Hydrocortisone (Solu-Cortef) Cimetidine (Tagamet)

Epinephrine

Which class of medication lyses and dissolves thrombi? Fibrinolytic Anticoagulant Platelet inhibitors Factor XA inhibitors

Fibrinolytic Thrombolytic (fibrinolytic) therapy lyses and dissolves thrombi in 50% of clients.

A client with lower extremity edema is diagnosed with lymphedema. For which medication will the nurse prepare teaching for this client? Oxycodone Furosemide Amoxicillin Heparin

Furosemide (Lasix) -> loop diuretic s/s: dizziness, headache, gastrointestinal upset, hyponatremia, hypokalemia and dehydration

The nurse has performed a thorough nursing assessment of the care of a client with chronic leg ulcers. The nurse's assessment should include which of the following components? Select all that apply. Location and type of pain Apical heart rate Bilateral comparison of peripheral pulses Comparison of temperature in the client's legs Identification of mobility limitations

Location and type of pain Bilateral comparison of peripheral pulses Comparison of temperature in the client's legs Identification of mobility limitations

When being assessed by her new nurse practitioner, a woman states that she has had Raynaud's disease for many years, a problem that occasionally affects her quality of life. When performing health education surrounding this problem, what should the nurse emphasize? Teaching the woman about atherosclerosis and its role in Raynaud's disease Teaching the woman about the correct use of anticoagulants Helping the woman identify and avoid the specific triggers of her problem Teaching the woman the signs and symptoms of deep vein thrombosis

Helping the woman identify and avoid the specific triggers of her problem The patient is instructed to avoid the stimuli (e.g., cold, tobacco) that provoke vasoconstriction.

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. Thrombosis of the graft. Decreased motor function. Stent dislodgement.

Hemorrhage.

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? Back or lumbar pain Hoarse voice and difficulty swallowing Abdominal swelling and tenderness Changes in bowel and bladder habits

Hoarse voice and difficulty swallowing

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? Surgical debridement Enzymatic debridement Hyperbaric oxygen Vacuum-assisted closure device

Hyperbaric oxygen

The nurse is caring for a patient with peripheral arterial insufficiency. What can the nurse suggest to help relieve leg pain during rest? Elevating the limb above heart level Lowering the limb so that it is dependent Massaging the limb after application of cold compresses Placing the limb in a plane horizontal to the body

Lowering the limb so that it is dependent

With a severe degree of peripheral arterial insufficiency, leg pain during rest can be reduced by: Elevating the limb over the heart level. Lowering the limb so that it is dependent. Massaging the limb after application of cold compresses. Placing the limb in a plane horizontal to the body.

Lowering the limb so that it is dependent.

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

In 3 to 5 days 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).

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

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

A 69-year-old man has been identified as having peripheral artery disease (PAD) and is motivated to slow the progression of the disease. Which of the following measures addresses the most common underlying cause of PAD? Maintaining a high level of physical activity Making lifestyle changes that address atherosclerosis Maintaining a diet that is high in antioxidants Making lifestyle changes that will reduce the patient's blood pressure

Making lifestyle changes that address atherosclerosis

A client is diagnosed with deep vein thrombosis (DVT). Which nursing diagnosis should receive highest priority at this time? Impaired gas exchange related to increased blood flow Excess fluid volume related to peripheral vascular disease Risk for injury related to edema Ineffective peripheral tissue perfusion related to venous congestion

Ineffective peripheral tissue perfusion related to venous congestion

The nurse is taking a health history on a new patient. The patient reports experiencing pain in the left lower leg and foot when walking, but claims that the pain is relieved with rest. The nurse notes that the patient's left lower leg is slightly edematous and hairless. What should the nurse suspect that the patient may be experiencing? Coronary artery disease (CAD) Intermittent claudication Arterial embolus Raynaud's disease

Intermittent claudication

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 Prothrombin time (PT) is 0.5 times normal. International normalized ratio (INR) is 2.5. K+ level is 3.5.

International normalized ratio (INR) is 2.5. 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 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 Very mild arterial insufficiency Tissue loss to that foot

Moderate to severe arterial insufficiency 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.

A nurse is assessing a client's right lower leg, which is wrapped with an elastic bandage. Which signs and symptoms suggest circulatory impairment? Numbness, cool skin temperature, and pallor Swelling, warm skin temperature, and drainage Numbness, warm skin temperature, and redness Redness, cool skin temperature, and swelling

Numbness, cool skin temperature, and pallor

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

Obesity

The nurse is caring for a patient who returned from the tropics 2 weeks ago. The patient has been diagnosed with lymphangitis and is experiencing lymphedema. You are aware that the lymphedema may be due to what? Obstructed lymph vessels Sensitivity to antibiotics Excessive lymph is the vascular space Improper anticoagulant use

Obstructed lymph vessels

The nurse is conducting a morning assessment of an older adult patient who has a history of peripheral artery disease. When palpating the patient's dorsalis pedis pulse, the nurse should: Palpate the pulses using the pads of his or her thumbs Thoroughly assess the right foot and then assess the left foot Palpate both of the patient's feet simultaneously Place his or her index finger on both of the patient's feet

Palpate both of the patient's feet simultaneously

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? Keep the extremities elevated slightly. Participate in a regular walking program. Use a heating pad to promote warmth. Massage the calf muscles if pain occurs.

Participate in a regular walking program.

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: Internal iliac. Common femoral. Popliteal. Posterior tibial.

Posterior tibial.

What nursing intervention is essential to appropriate care of a patient post thrombolysis

Preforming a baseline assessment of the extremity To monitor patients postintervention, it is essential that a baseline assessment of the extremity is documented so that the nurse can determine changes in perfusion of the extremity postprocedure. The patient is monitored closely for any signs of bleeding, as this is the most common side effect of thrombolytic therapy. Avoiding both IM injects and pressure application after blood draws supports that care need. The administration of the thrombolytic agent is related to lyse of the thrombus itself.

While receiving heparin to treat a pulmonary embolus, a client passes bright red urine. What should the nurse do first? Decrease the heparin infusion rate. Prepare to administer protamine sulfate. Monitor the partial thromboplastin time (PTT). Start an I.V. infusion of dextrose 5% in water (D5W).

Prepare to administer protamine sulfate.

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? Phytonadione (vitamin K) Protamine sulfate Thrombin Plasma protein fraction

Protamine sulfate

Which of the following is the most common site for a dissecting aneurysm? Thoracic area Lumbar area Sacral area Cervical area

Thoracic area

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

Raynaud's disease

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

Risk factor modification

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 A cerebral vascular bleed 10 years ago Three vaginal births, the most recent 18 months ago Diet that includes many green, leafy vegetables every day

Scheduled eye surgery in 1 week

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 Engaging in anaerobic exercise 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

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. Inform the physician if the client's temperature remains low. Avoid elevating the area. Offer cold applications to promote comfort and to enhance circulation.

Teach the client how to apply a graduated compression stocking.

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 Inform the physician if the client's temperature remains low Avoid elevating the area Offer cold applications to promote comfort and to enhance circulation

Teach the client how to apply an elastic sleeve

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.

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

Ulcers and infection in the edematous area the tissue nutrition is impaired as a result of the stagnation of lymphatic fluid, leading to ulcers and infection in the edematous area.

The nurse at a long-term care facility is conducting an admission assessment of a new resident. On inspection of the resident's lower extremities, the nurse notes that the shins and ankles have a gray-brown color tone and are visibly shiny. The nurse should conduct further assessments in light of the possibility that the resident may have: Venous insufficiency An arterial occlusion Raynaud's disease A deep vein thrombosis

Venous insufficiency

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? Arterial insufficiency Venous insufficiency Neither venous nor arterial insufficiency Trauma

Venous insufficiency 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 caring for a patient diagnosed with peripheral arterial disease. Based on assessment, which clinical manifestation would be consistent with acute arterial occlusion? Select all that apply. Pallor Paresthesia Hyperthermia Poikilothermia Loss of toe hairs

a, b, d. When assessing acute arterial occlusion, the nurse must be aware of the "six Ps": pain, pallor, pulselessness, poikilothermia, paresthesia, and paralysis. Hyperthermia is not associated with decreased arterial perfusion, but a cool limb is, thus the conclusion of poikilothermia. Loss of toe hairs is associated with chronic peripheral arterial disease, it is not an acute finding.

Which of the following findings are associated with a possible DVT? Select all that apply. Calf tenderness Unilateral limb edema 1+ pedal pulse Cool limb Atrophy of the limb

a, b. Calf tenderness is produced by inflammation of the vein wall, and a cord may be detected in the involved veins by gently palpating the affected extremity. Deep vein thrombosis (DVT) is associated with edema of the extremity due to inhibition of venous outflow. Swelling can be measured by obtaining the circumference of the affected extremity at specific levels and comparing one extremity with the other at the same level (e.g., 3 cm difference at midcalf area [10 cm below the tibial tuberosity]). Decreased peripheral pulse is associated with arterial disease; recall DVT is a venous problem. Atrophy of the limb is associated with PAD, among other causes.

A new postsurgical patient has been prescribed unfractionated heparin to prevent DVT. What is a true statement regarding the use of heparin? Select all that apply. Heparin has a half-life of approximately 60 minutes. Therapeutic PT level is 1.5 to 2.5 times the baseline control. Vitamin K interferes with the action of heparin. Heparin is administered by gravity drip. Therapeutic aPTT level is 1.5 to 2.5 times the baseline control.

a, f. Heparin has a half-life of about 60 minutes. Heparin is in effective, or therapeutic, range when the activated partial thromboplastin tine (aPTT) is 1.5 to 2.5 times the baseline control. If renal insufficiency exists, lower doses of heparin are required. Unfractionated heparin is administered via an infusion pump to carefully control the rate. Therapeutic PT is used to assess the therapeutic range of warfarin.

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 exercise electrocardiography electron beam computed tomography photoplethysmography

ankle-brachial index

The nurse is using a hydrocolloid dressing for a patient who is undergoing autolytic debridement of a necrotic venous ulcer. What is characteristic of this type of debridement? Select all that apply. Accomplished by applying enzymatic ointment to the lesion Left in place for 3 to 7 days The fastest method of debridement Accomplished by applying saline impregnated gauze to the ulcer Assists with the removal of necrotic tissue while preserving viable tissue

b, f. With autolytic debridement, an occlusive absorptive dressing, such as a hydrocolloid, is placed over the wound and left in place for 3 to 7 days to allow enzymes from the body to liquefy the necrotic tissue and separate it from the viable tissue. Enzymatic debridement involves the application of enzyme ointments prescribed to treat the ulcer. Surgical debridement is the fastest method of debridement. Wet to dry or nonselective debridement can be accomplished by applying saline impregnated gauze to the ulcer.

A client with suspected lymphoma is scheduled for lymphangiography. The nurse should inform the client that this procedure may cause which harmless temporary change? Purplish stools Bluish urine Redness of the upper part of the feet Coldness of the soles

bluish urine

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? Arm sling Aspirin therapy Physical therapy Compression sleeve

compression sleeve

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 air plethysmography. contrast phlebography. lymphangiography. lymphoscintigraphy.

contrast phlebography.

Which characteristic is consistent with an arterial ulcer? Select all that apply. a. Pink or beefy red appearance with granulation tissue b. May have severe edema c. Darkened color tissue in gaiter area d. Pale and cool extremity e. Pale wound base

d, e. Arterial ulcers have a regular border, are pale, and are cooler than other skin areas. Venous ulcers may be pink or beefy red in color. Tissue is darker in the gaiter area, and there may be severe edema and drainage.

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

decreases venous congestion. Regular walking is the best way to decrease venous congestion because using the leg muscles as a pump helps return blood to the heart

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

elevational pallor. 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.

Arterial occlusions from atherosclerosis occur more frequently in the upper extremities than in the legs

false

T or F Anticoagulants dissolve the thrombus that has already formed

false

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: place a heating pad around the affected calf. elevate the affected leg as high as possible. keep the affected leg level or slightly dependent. shave the affected leg in anticipation of surgery.

keep the affected leg level or slightly dependent. 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.

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: pallor and coolness of the left foot. a decrease in the left pedal pulse. loss of hair on the lower portion of the left leg. left calf circumference 1" (2.5 cm) larger than the right.

left calf circumference 1" (2.5 cm) larger than the right.

What is the primary objection in the postprocedural period of a balloon angioplasty involving the left leg?

maintaining circulation

What is the hallmark symptom of peripheral artery disease (PAD) in the lower extremity?

pain Peripheral artery disease (PAD) refers to any disease process that affects the arteries. Various PADs result in ischemia with its hallmark symptom in the lower extremity being intermittent claudication. Intermittent claudication is caused by the inability of the arterial system to provide adequate blood flow to the tissues in the face of increased demand for nutrients and oxygen during exercise. Inadequate blood flow results in cool and pale extremities along with dry, scaly skin.

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? Cyanosis Gangrene Pallor Ulceration

pallor Pallor is the initial symptom in Raynaud syndrome followed by cyanosis and aching pain.

T or F All aneurysms involve a damaged media layer of the vessel

true

T or F Heparin has a half-life of about 60 minutes

true

T or F The thoracic area is the most common site for a dissecting aneurysm.

true