Chapter 26 - Assessment and Management of Patients with Vascular Disorders and Disorders of Peripheral Circulation

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. A pulsatile abdominal mass B. Low back pain C. Decreased bowel sounds D. Diarrhea E. Lower abdominal pain

A. A pulsatile abdominal mass B. Low back pain E. 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.

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. A ripping sensation in the chest B. Numbness and pain of the left arm C. Gradual onset of a frontal headache D. Pain when flexing the neck forward

A. 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? A. Alteplase B. Heparin C. Coumadin DLovenox

A. Alteplase 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: A. Alteplase. B. Streptokinase C. Reteplase. D. Urokinase.

A. Alteplase. Alteplase has fewer disadvantages than the other thrombolytic agents. Refer to Table 18-2 in the text.

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? A. Arterial insufficiency B. Venous insufficiency C. Neither venous nor arterial D. Trauma

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

A. Attempt to palpate the dorsalis pedis and posterior tibial pulses. 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 of the following is a characteristic of an arterial ulcer? A. Border regular and well demarcated B. Ankle-brachial index (ABI) > 0.90 C. Edema may be severe D. Brawny edema

A. Border regular and well demarcated 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.

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? A. Compression sleeve B. Physical therapy C. Arm sling D. Aspirin therapy

A. Compression Sleeve 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.

Which is a characteristic of arterial insufficiency? A. Diminished or absent pulses B. Superficial ulcer C. Aching, cramping pain D. Pulses are present but may be difficult to palpate

A. 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.

The nurse assessing a client who has arterial insufficiency of the legs and an ulcer on the left great toe would expect to find which characteristic? A. Diminished or absent pulses B. Pulses that are present but difficult to palpate C. Aching, cramping pain D. Superficial ulcer

A. Diminished or absent pulses Explanation: Occlusive arterial disease impairs blood flow and can reduce or obliterate palpable pulsations in the extremities. A diminished or absent pulse is a characteristic of arterial insufficiency.

Which aneurysm results in bleeding into the layers of the arterial wall? A. Dissecting B. Anastomotic C. False D. Saccular

A. 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.

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

A. Dorsiflex the foot while the leg is elevated to check for calf pain. Homan's sign is indicated by pain in the calf after the foot is sharply dorsiflexed.

Which class of medication lyses and dissolves thrombi? A. Fibrinolytic B. Anticoagulant C. Platelet inhibitors D. Factor XA inhibitors

A. 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: A. Hemorrhage. B. Thrombosis of the graft. C. Decreased motor function. D. Stent dislodgement.

A. Hemorrhage. Explanation: All choices are serious and require medical/surgical intervention. However, hemorrhage is the most serious complication that requires immediate attention.

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? A. Keeping the legs in a neutral or dependent position B. Application of ace wraps from the toe to below the knees C. Use of antiembolic stockings D. Elevation of the legs above the heart

A. Keeping the legs in a neutral or dependent position 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.

A nurse assesses a patient for a possible abdominal aortic aneurysm (AAA). Which of the following signs would the nurse recognize as positive indicators? Select all that apply. A. Low back pain B. Lower abdominal pain C. Hypertension D. An abdominal pulsatile mass E. A systolic bruit F. Radiating chest pain

A. Low back pain B. Lower abdominal pain D. An abdominal pulsatile mass E. A systolic bruit

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? A. Moderate to severe arterial insufficiency B. No arterial insufficiency C. Very mild arterial insufficiency D. Tissue loss to that foot

A. 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.

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? A. Nonselective debridement B. Enzymatic debridement C. Surgical debridement D. Selective debridement

A. 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.

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? A. Peripheral pulses every 15 minutes after surgery B. Ankle-arm indices every 12 hours C. Blood pressure every 2 hours D. Color of the leg every 4 hours

A. 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: A. Posterior tibial. B. Internal iliac. C. Common femoral. D. Popliteal.

A. 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.

The nurse is caring for a client who is known to have a high risk for venous thromboembolism. What preventive actions should the nurse recommend? Select all that apply. A. Regular exercise B. Smoking cessation C. Weight loss D. Calcium and vitamin D supplementation D. High-protein diet

A. Regular exercise B. Smoking cessation C. Weight loss

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? A. Stop smoking. B. Wear antiembolic stockings daily to assist with blood return to the heart. C. Keep your feet elevated above your heart. D. Do not cross your legs for more than 30 minutes at a time.

A. Stop smoking. Explanation: Nicotine from tobacco products causes vasospasm and can thereby dramatically reduce circulation to the extremities. When the client elevates the feet above the heart level, the heart must work against gravity to supply blood to the feet. Antiembolic stocking are helpful for venous return to the heart, but constriction is not helpful for lack of arterial blood flow. Crossing the legs for more than a few minutes at a time compresses arteries and decreases blood supply to the legs and feet.

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

A. Taking daily walks Explanation: Taking daily walks relieves symptoms of intermittent claudication, although the exact mechanism is unclear. Anaerobic exercise may make these symptoms worse. Clients with chronic arterial occlusive disease must reduce daily fat intake to 30% or less of total calories. The client should limit dietary cholesterol because hyperlipidemia is associated with atherosclerosis, a known cause of arterial occlusive disease. However, HDLs have the lowest cholesterol concentration, so this client should eat, not abstain from, foods that raise HDL levels.

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? A. The client is at risk for heparin-induced thrombocytopenia; therefore, the care plan should include reporting evidence of bleeding or easy bruising. B. 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. C. 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.

A. 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.

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

A. The client will be immobile during and shortly after surgery. Postoperative immobility and subsequent venous stasis predispose the client to deep vein thrombosis. Other predisposing factors for this condition include obesity and current pregnancy, which don't apply to this client. Exercise isn't a risk factor for deep vein thrombosis.

Which of the following is the most common site for a dissecting aneurysm? A. Thoracic area B. Lumbar area C. Sacral area D. Cervical area

A. Thoracic area 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.

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

A. 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. Regular exercise also aids in stress reduction and weight reduction and increases the formation of HDLs — which are all beneficial to a client with peripheral vascular disease. However, these changes don't have as significant an effect on the client's condition as decreasing venous congestion.

The nurse teaches the client with peripheral vascular disease (PVD) to refrain from smoking because nicotine causes A. vasospasm. B. slowed heart rate. C. depression of the cough reflex. D. diuresis.

A. vasospasm. Nicotine causes vasospasm and can thereby dramatically reduce circulation to the extremities. Tobacco smoke also impairs transport and cellular use of oxygen and increases blood viscosity. Clients with arterial insufficiency who smoke or chew tobacco must be fully informed of the effects of nicotine on circulation and be encouraged to stop.

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? A. "It is important to apply sunscreen to the top of my feet when wearing sandals." B. "Shoes made of synthetic material are best for my feet." C. "I should apply powder daily because my feet perspire." D. "I can use lamb's wool between my toes if necessary."

B. "Shoes made of synthetic material are best for my feet." The client should wear leather shoes with an extra-depth toe box. Synthetic shoes do not allow air to circulate.

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? A. Adequate carbohydrate intake B. Application of graduated compression stockings C. Methods of keeping the wound area dry D. Prophylactic antibiotic therapy

B. Application of graduated compression stockings Graduated compression stockings usually are prescribed for clients with venous insufficiency. The required pressure gradient is determined by the amount and severity of venous disease. Graduated compression stockings are designed to apply 100% of the prescribed pressure gradient at the ankle and pressure that decreases as the stocking approaches the thigh, reducing the caliber of the superficial veins in the leg and increasing flow in the deep veins. These stockings may be knee high, thigh high, or pantyhose.

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

B. Furosemide

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? A. Enzymatic debridement B. Hyperbaric oxygen C. Surgical debridement D. Vacuum-assisted closure device

B. 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 is caring for a patient who has started anticoagulant therapy with warfarin (Coumadin). When does the nurse understand that therapeutic benefits will begin? A. Within the first 24 hours B. In 3 to 5 days C. Within 12 hours D. In 2 days

B. In 3 to 5 days Explanation: 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)

Which observation regarding ulcer formation on the client's lower extremity indicates to the nurse that the ulcer is a result of venous insufficiency? A. Is deep, involving the joint space B. Large and superficial C. Base is pale to black D. Though superficial, is very painful

B. Large and superficial Ulcerations are in the area of the medial or lateral malleolus (gaiter area) and are typically large, superficial, and highly exudative. Superficial venous insufficiency ulcers cause minimal pain. The base of a venous insufficiency ulcer shows a beefy red to yellow fibrinous color.

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

B. Lowering the limb so that it is dependent. Lowering the extremity to a dependent position improves perfusion to the distal tissues.

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

B. Numbness, cool skin temperature, and pallor Explanation: Signs and symptoms of impaired circulation include numbness and cool, pale skin. Signs of localized infection may include swelling, drainage, redness, and warm skin. Signs of adequate circulation include normal sensation and warm skin with normal return of skin color after blanching.

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

B. Participate in a regular walking program. Explanation: Clients diagnosed with peripheral arterial occlusive disease should be encouraged to participate in a regular walking program to help develop collateral circulation. They should be advised to rest if pain develops and to resume activity when pain subsides. Extremities should be kept in a dependent position to promote circulation; elevation of the extremities will decrease circulation. Heating pads should not be used by anyone with impaired circulation to avoid burns. Massaging the calf muscles will not decrease pain. Intermittent claudication subsides with rest.

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? A. Diet that includes many green, leafy vegetables every day B. Scheduled eye surgery in 1 week C. Three vaginal births, the most recent 18 months ago D. A cerebral vascular bleed 10 years ago

B. Scheduled eye surgery in 1 week Contraindications to anticoagulant therapy include recent or impending eye surgery, recent cerebral vascular bleeds, and recent childbirth. A diet including green leafy vegetables is not a contraindication.

A client with a diagnosed abdominal aortic aneurysm (AAA) develops severe lower back pain. Which is the most likely cause? A. The aneurysm has become obstructed. B. The aneurysm may be preparing to rupture. c. The client is experiencing inflammation of the aneurysm. D. The client is experiencing normal sensations associated with this condition.

B. The aneurysm may be preparing to rupture. 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.

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

B. 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.

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

C. "The enoxaparin will work immediately, but the warfarin takes several days to achieve its full effect." Oral anticoagulants such as warfarin are monitored by the prothrombin time (PT) or the international normalized ratio (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 assisting a patient with peripheral arterial disease to ambulate in the hallway. What should the nurse include in the education of the patient during ambulation? A. "As soon as you feel pain, we will go back and elevate your legs." B. "If you feel pain during the walk, keep walking until the end of the hallway is reached." C. "Walk to the point of pain, rest until the pain subsides, then resume ambulation." D. "If you feel any discomfort, stop and we will use a wheelchair to take you back to your room."

C. "Walk to the point of pain, rest until the pain subsides, then resume ambulation." Explanation: The nurse instructs the patient to walk to the point of pain, rest until the pain subsides, and then resume walking so that endurance can be increased as collateral circulation develops. Pain can serve as a guide in determining the appropriate amount of exercise.

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

C. An incompetent venous valve.

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? A. Contrast phlebography B. Lymphangiography C. Duplex ultrasound scan D. Lymphoscintigraphy

C. Duplex ultrasound scan Diagnostic tests for varicose veins include the duplex ultrasound scan, which documents the anatomic site of reflux and provides a quantitative measure of the severity of valvular reflux. Contrast phlebography involves injecting a radiopaque contrast agent into the venous system. Lymphoscintigraphy is done when a radioactively labeled colloid is injected subcutaneously in the second interdigital space. The extremity is then exercised to facilitate the uptake of the colloid by the lymphatic system, and serial images are obtained at preset intervals. Lymphangiography provides a way to detect lymph node involvement resulting from metastatic carcinoma, lymphoma, or infection in sites that are otherwise inaccessible to the examiner except by surgery.

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

C. Elevate the legs periodically for at least 15 to 20 minutes. Explanation: The nurse should advise the client to periodically elevate the legs for at least 15 to 20 minutes. Avoiding foods with iodine or refraining from sexual activity for a week does not relate to venous insufficiency.

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? A. Enzymatic debridement B. Surgical debridement C. Hyperbaric oxygen D. Vacuum-assisted closure device

C. 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.

Which of the following is the hallmark symptom for peripheral arterial disease (PAD) in the lower extremity? A. Dizziness B. Vertigo C. Intermittent claudication D. Acute limb ischemia

C. 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.

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

C. Prepare to administer protamine sulfate. 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 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? A. Platelet count B. Partial thromboplastin time (PTT) C. Prothrombin time (PT) D. Bleeding time

C. Prothrombin Time (PT) 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.

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? A. Bleeding time B. Platelet count C. Prothrombin time (PT) D. Partial thromboplastin time (PTT)

C. Prothrombin time (PT) 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.

A female client is readmitted to the facility with a warm, tender, reddened area on her right calf. Which contributing factor should the nurse recognize as most important? A. A history of diabetes mellitus B. History of increased aspirin use C. Recent pelvic surgery D. An active daily walking program

C. Recent pelvic surgery Explanation: The client shows signs of deep vein thrombosis (DVT). The pelvic area has a rich blood supply, and thrombophlebitis of the deep veins is associated with pelvic surgery. Aspirin, an antiplatelet agent, and an active walking program help decrease the client's risk of DVT. In general, diabetes mellitus is a contributing factor associated with peripheral vascular disease.

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

C. 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.

Which client with a venous stasis ulcer is a candidate for topical hyperbaric oxygen therapy? A. a nonambulatory client B. a client with an infected stasis ulcer C. a client with a chronic, nonhealing skin lesion D. a client whose ulcer includes necrotic tissue

C. a client with a chronic, nonhealing skin lesion 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.

Vasodilation or vasoconstriction produced by an external cause will interfere with a nurse's accurate assessment of a client with peripheral vascular disease (PVD). Therefore, the nurse should: A. maintain room temperature at 78° F (25.6° C). B. match the room temperature to the client's body temperature. C. keep the client warm. D. keep the client uncovered.

C. keep the client warm. The nurse should keep the client covered and expose only the portion of the client's body that she's assessing. The nurse should also keep the client warm by maintaining his room temperature between 68° F and 74° F (20° and 23.3° C). Extreme temperatures aren't good for clients with PVD. The valves in their arteries and veins are already insufficient, and exposing them to vast changes in temperature could affect assessment findings. Keeping the client uncovered would cause him to become chilled. Matching the room temperature to the client's body temperature is inappropriate.

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

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

The nurse instructs a client with Raynaud phenomenon on actions to improve the symptoms. Which client statement indicates the need for additional instruction? A. "I will avoid stressful situations." B. "I will wear gloves when taking food out of the freezer." C. "I will put on gloves before opening a cold car door." D. "I will limit the amount of cigarettes I smoke."

D. "I will limit the amount of cigarettes I smoke." Raynaud phenomenon is a form of intermittent arteriolar vasoconstriction that results in coldness, pain, and pallor of the fingertips or toes. Patients should avoid all forms of nicotine, which may induce attacks; this includes nicotine gum or patches used to aid smoking cessation. The client should be instructed to avoid situations that may be stressful as this could trigger an attack. Wearing gloves before opening a cold car door and when taking food out of the freezer should also be done as this could trigger vasoconstriction and an attack.

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? A. 0.10 B. 0.25 C. 0.35 D. 0.50

D. 0.50 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.

When caring for a patient who has started anticoagulant therapy with warfarin (Coumadin), the nurse knows that therapeutic benefits will not occur for: A. 2 to 3 days. B. The first 24 hours. C. At least 12 hours. D. 3 to 5 days.

D. 3 to 5 days. It takes 3 to 5 days for a therapeutic international normalized ratio (INR) to be achieved. Therefore, Coumadin is given concurrently with heparin until a therapeutic level is established, usually within 72 hours.

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

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

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? A. 20 B. 30 C. 40 D. 50

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

Which of the following assessment results is considered a major risk factor for PAD? A. LDL of 100 mg/dL B. Cholesterol of 200 mg/dL C. Triglyceride level of 150 mg/dL D. BP of 160/110 mm Hg

D. BP of 160/110 mm Hg Hypertension is considered a major risk factor for PAD. Blood pressure should be less than 130/90 mm Hg. The other laboratory results are within the recommended range of normal to high normal.

Pentoxifylline (Trental) is a medication used for which of the following conditions? A. Elevated triglycerides B. Hypertension C. Thromboemboli D. Claudication

D. Claudication 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 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? A. Arm sling B. Aspirin therapy C. Physical therapy D. Compression sleeve

D. 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.

Which statement is accurate regarding Raynaud disease? A. The disease generally affects the client trilaterally. B. It affects more than two digits on each hand or foot. C. It is most common in men 16 to 40 years of age. D. Episodes may be triggered by unusual sensitivity to cold.

D. Episodes may be triggered by unusual sensitivity to cold. Explanation: Episodes of Raynaud disease may be triggered by emotional factors or by unusual sensitivity to cold. The disease is most common in women between 16 and 40 years of age. It is generally unilateral and affects only one or two digits.

Aortic dissection may be mistaken for which of the following disease processes? A. Stroke B. Pneumothorax C. Angina D. Myocardial infarction (MI)

D. 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.

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? A. Gangrene B. Cyanosis C. Ulceration D. Pallor

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

D. The client can walk about 50 feet before getting pain in the right lower leg. Explanation: Intermittent claudication is caused by the inability of the arterial system to provide adequate blood flow to the tissues when increased demands are made for oxygen and nutrients during exercise. Pain is then experienced. When the client rests and decreases demands, the pain subsides. The client can then walk the same distance and repeat the process.

The nurse is caring for a patient with venous insufficiency. For what should the nurse assess the patient's lower extremities? A. Rubor B. Cellulitis C. Dermatitis D. Ulceration

D. 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.

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? A. Neither venous nor arterial insufficiency B. Arterial insufficiency C. Trauma D. Venous insufficiency

D. 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 most common site of aneurysm formation is in the: A. descending aorta, beyond the subclavian arteries. B. ascending aorta, around the aortic arch. C. aortic arch, around the ascending and descending aorta. D. abdominal aorta, just below the renal arteries.

D. abdominal aorta, just below the renal arteries. 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.

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

D. 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.

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

D. keep the affected leg level or slightly dependent. Explanation: 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.