Ch 30
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.
A client is recovering from surgical repair of a dissecting aortic aneurysm. Which assessment findings indicate possible bleeding or recurring dissection?
Blood pressure of 82/40 mm Hg and heart rate of 125 beats/minute Assessment findings that indicate possible bleeding or recurring dissection include hypotension with reflex tachycardia (as evidenced by a blood pressure of 82/40 mm Hg and a heart rate of 125 beats/minute), decreased urine output, and unequal or absent peripheral pulses. Hematuria, increased urine output, and bradycardia aren't signs of bleeding from aneurysm repair or recurring dissection
Which of the following are alterations noted in Virchow's triad? Select all that apply.
Stasis of blood Vessel wall injury Altered coagulation Three factors, known as Virchow's triad, are believed to play a significant role in the development of venous thrombosis. They are stasis of blood, vessel wall injury, and altered coagulation. Edema and tenderness are clinical manifestations of venous thrombosis, but are not part of the triad
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. 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 nurse is caring for a patient with venous insufficiency. For what should the nurse assess the patient's lower extremities?
Ulceration Explanation: Venous ulceration is the most serious complication of chronic venous insufficiency and can be associated with other conditions affecting the circulation of the lower extremities. Cellulitis or dermatitis may complicate the care of chronic venous insufficiency and venous ulcerations
What symptoms should the nurse assess for in a client with lymphedema as a result of impaired nutrition to the tissue?
Ulcers and infection in the edematous area 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.
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
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:
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
Which aneurysm results in bleeding into the layers of the arterial wall?
dissecting 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.
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
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.
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. A normal PTT level is 21 to 35 seconds. A reading of more than 100 seconds indicates a significant risk of hemorrhage.
The nurse is assessing a client with severe hypertension. Which symptom indicates to the nurse that the client is experiencing dissection of the aorta?
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.
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?
Avoid situations that contribute to ischemic episodes.
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. 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.
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. 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?
Fibrinolytic
Which sign or symptom suggests that a client's abdominal aortic aneurysm is extending?
Increased abdominal and back pain 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.
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. 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)
The nurse is caring for a patient with peripheral arterial insufficiency. What can the nurse suggest to help relieve leg pain during rest?
Lowering the limb so that it is dependent. Persistent pain in the forefoot (i.e., the anterior portion of the foot) when the patient is resting indicates a severe degree of arterial insufficiency and a critical state of ischemia. Known as rest pain, this discomfort is often worse at night and may interfere with sleep. This pain frequently requires that the extremity be lowered to a dependent position to improve perfusion to the distal tissues.
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?
Pallor Explanation: Pallor is the initial symptom in Raynaud syndrome followed by cyanosis and aching pain. Gangrene and ulceration can occur with persistent attacks and interference of blood flow.
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. 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
A physician admits a client to the health care facility for treatment of an abdominal aortic aneurysm. When planning this client's care, which goal should the nurse keep in mind as she formulates interventions?
Stabilizing heart rate and blood pressure and easing anxiety's For a client with an aneurysm, nursing interventions focus on preventing aneurysm rupture by stabilizing heart rate and blood pressure. Easing anxiety also is important because anxiety and increased stimulation may raise the heart rate and boost blood pressure, precipitating aneurysm rupture. The client with an abdominal aortic aneurysm is typically hypertensive, so the nurse should take measures to lower blood pressure, such as administering antihypertensive agents, as ordered, to prevent aneurysm rupture. To sustain major organ perfusion, the client should maintain a mean arterial pressure of at least 60 mm Hg. Although the nurse must assess each client's mobility individually, most clients need bed rest when initially attempting to gain stability
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
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.
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. 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.
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?
arterial insufficiency
Which of the following is the hallmark symptom for peripheral arterial disease (PAD) in the lower extremity?
intermittent claudication 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
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 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 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 Low back pain Lower abdominal pain Some patients complain that they can feel their heart beating in their abdomen when lying down, or they may say that they feel an abdominal mass or abdominal throbbing. The most important diagnostic indication of an abdominal aortic aneurysm is a pulsatile mass in the middle and upper abdomen. Signs of impending aneurysm rupture include severe back or abdominal pain, which may be persistent or intermittent. Abdominal pain is often localized in 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.
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. Explanation: Nicotine decreases blood flow, increases heart rate and blood pressure, and increases the risk for clot formation by increasing platelet aggregation. Smokers have a four-fold higher risk of developing pain from arterial disease than nonsmokers. Carbon monoxide, produced by burning tobacco, combines with hemoglobin more readily than oxygen, thus depriving tissues of oxygen
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?
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
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 When a thrombus exists, an x-ray image will disclose an unfilled segment of a 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.
Which is a characteristic of arterial insufficiency
Diminished or absent pulses
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 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 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?
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.
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. In severe cases of lymphangitis and lymphadenitis with persistent swelling, the nurse teaches the client how to apply a graduated compression 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
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
A nurse is instructing a client about using antiembolism stockings. Antiembolism stockings help prevent deep vein thrombosis (DVT) by
forcing blood into the deep venous system. Antiembolism stockings prevent DVT by forcing blood into the deep venous system, instead of allowing blood to pool. Ambulation prevents blood from pooling and prevents DVT, but encouraging ambulation isn't a function of the stockings. Antiembolism stockings could possibly provide warmth, but this factor isn't how they prevent DVT. Elevating the extremity decreases edema but doesn't prevent DVT.
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 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 is performing wound care for a patient with a necrotic sacral wound. The prescribed treatment is isotonic saline solution with fine mesh gauze and a dry dressing to cover. What type of debridement is the nurse performing?
nonselective debridement Nonselective débridement can be accomplished by applying isotonic saline dressings of fine mesh gauze to the ulcer. When the dressing dries, it is removed (dry), along with the debris adhering to the gauze. Pain management is usually necessary.
The nurse is caring for a client with abdominal aortic aneurysm (AAA). Which assessment finding is most likely to indicate a dissection of the aneurysm?
severe back pain Pressure from an enlarging or dissecting abdominal aortic aneurysm is likely to be exhibited as severe pain. A decrease in blood pressure will result as the client goes into shock from hemorrhaging. Blood in emesis or rectal bleeding is not associated with rupture of AAA.
The most important factor regulating the caliber of blood vessels, which determines resistance to flow, is:
sympathetic nervous system
A nurse is providing education about the prevention of arterial constriction to a client with peripheral arterial disease. Which of the following includes priority information the nurse would give to the client?
to stop smoking.
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
