N144 Unit 3 Exam

Buerger's disease is characterized by all of the following:

* Arterial thrombosis formation and occlusion * Redness or cyanosis in the limb when it is dependent * Venous inflammation and occlusion

Significant causes of venous thrombosis is:

* altered blood coagulation * stasis of blood * vessel wall injury

A nurse is caring for a client who had a percutaneous insertion of an inferior vena cava filter and was on heparin therapy before surgery. The nurse would inspect the surgical site most closely for signs of:

Bleeding and infection * explanation: After inferior vena cava insertion, the nurse inspects the surgical site for bleeding and signs and symptoms of infection. Otherwise, care is the same as for any post-op client.

Varicose veins can cause changes in what component of Virchow's triad?

Blood flow

A nurse is assessing a client with an abdominal aortic aneurysm. Which of the following assessment findings by the nurse is probably unrelated to the aneurysm? 1) Pulsatile abdominal mass 2) Hyperactive bowel sounds in that area 3) Systolic bruit over the area of the mass 4) Subjective sensation of "heart beating" in the abdomen

Hyperactive bowl sounds in that area * explanation: Not all clients with abdominal aortic aneurysms exhibit symptoms. Those who do describe a feeling of the "heart beating" in the abdomen when supine or be able to feel the mass throbbing. A pulsatile mass may be palpated in the middle and upper abdomen. A systolic bruit may be auscultated over the mass. Hyperactive bowel sounds are not related specifically to an abdominal aortic aneurysm.

In preparation for discharge of a client with arterial insufficiency and Raynaud's disease, client teaching instructions should include:

Keeping the heat up so that the environment is warm * Explanation: The client's instructions should include keeping the environment warm to prevent vasoconstriction. Wearing gloves, warm clothes, and socks will also be useful when preventing vasoconstriction, but TED hose would not be therapeutic. Walking would most likely increase pain.

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

Lowering the limb so it is dependent

A client comes to the outpatient clinic and tells the nurse that he has had legs pains that began when he walks but cease when he stops walking. Which of the following conditions would the nurse assess for?

Peripheral vascular problems in both legs * Explanation: Intermittent claudication is a condition that indicates vascular deficiencies in the peripheral vascular system. If an obstruction were present, the leg pain would persist when the client stops walking. Low calcium levels may cause leg cramps but would not necessarily be related to walking.

When caring for a patient who has started anticoagulant therapy with warfarin (Coumadin), the nurse knows not to expect therapeutic benefits for:

2-3 days

Mike, a 43-year old construction worker, has a history of hypertension. He smokes two packs of cigarettes a day, is nervous about the possibility of being unemployed, and has difficulty coping with stress. His current concern is calf pain during minimal exercise that decreased with rest. The nurse assesses Mike's symptoms as being associated with peripheral arterial occlusive disease. The nursing diagnosis is probably:

Alteration in tissue perfusion related to compromised circulation

Cancer can cause changes in what component of Virchow's triad?

Blood coagulability

A client is admitted with a venous stasis leg ulcer. A nurse assesses the ulcer, expecting to note that the ulcer:

Has brown pigmentation around it * Explanation: Venous leg ulcers, also called stasis ulcers, tend to be more superficial than arterial ulcers, and the ulcer bed is pink. The edges of the ulcer are uneven, and granulation tissue is evident. The skin has a brown pigmentation from accumulation of metabolic waste products resulting from venous stasis. The client also exhibits peripheral edema.

A client who has been receiving heparin therapy also is started on warfarin sodium (coumadin). The client asks the nurse why both medications are being administered. In formulating a response, the nurse incorporates the understanding that warfarin sodium:

Inhibits synthesis of specific clotting factors in the liver, and it takes 3 to 4 days for this medication to exert an anticoagulation effect. * explination: Warfarin sodium works in the liver and inhibits synthesis of four vitamin K-dependent clotting factors (X, IX, VII, and II), but it takes 3 to 4 days before the therapeutic effect of warfarin is exhibited.

A nurse is assessing the neurovascular status of a client who returned to the surgical nursing unit 4 hours ago after undergoing aortoiliac bypass graft. The affected leg is warm, and the nurse notes redness and edema. The pedal pulse is palpable and unchanged from admission. The nurse interprets that the neurovascular status is:

Normal because of the increased blood flow through the leg * explanation: An expected outcome for surgery is warmth, redness, and edema in the surgical extremity because of increased blood flow.

Intravenous heparin therapy is ordered for a client. While implementing this order, a nurse ensures that which of the following medications is available on the nursing unit?

Protamine sulfate *explanation: the antidote to heparin is protamine sulfate and should be readily available for use if excessive bleeding or hemorrhage should occur.

Which of the following characteristics is typical of the pain associated with DVT?

Sudden onset *Explanation: DVT is associated with deep leg pain of sudden onset, which occurs secondary to the occlusion. A dull ache is more commonly associated with varicose veins. A tingling sensation is associated with an alteration in arterial blood flow. If the thrombus is large enough, it will cause pain.

The most important factor in regulating the caliber of blood vessels, which determines resistance to flow, is:

The sympathetic nervous system

Which technique is considered the gold standard for diagnosing DVT?

Venography

A nurse has an order to begin administering warfarin sodium (coumadin) to a client. While implementing this order, the nurse ensures that which of the following medications is available on the nursing unit as the antidote for Coumadin?

Vitamin K * explanation: The antidote to warfarin (Coumadin) is Vitamin K and should be readily available for use if the excessive bleeding or hemorrhage should occur.

a 24- year old man seeks medical attention for complaints of claudication in the arch of the foot. A nurse also notes superficial thrombophlebitis of the lower leg. The nurse would next assess the client for:

smoking history *reasoning: The mixture of arterial and venous manifestations (claudication and phlebitis, respectively) in the young male client suggests Buerger's disease. This is an uncommon disorder characterized by inflammation and thrombosis of smaller arteries and veins. This disorder typically is found in young adult males who smoke. The cause is not known precisely but is suspected to have an autoimmune component.