Chapter 30
Correct response: 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 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.
Correct response: Ineffective peripheral tissue perfusion related to venous congestion Explanation: Ineffective peripheral tissue perfusion related to venous congestion takes highest priority because venous inflammation and clot formation impede blood flow in a client with DVT. Impaired gas exchange related to increased blood flow is incorrect because impaired gas exchange is related to decreased, not increased, blood flow. Excess fluid volume related to peripheral vascular disease is inappropriate because there's no evidence that this client has an excess fluid volume. Risk for injury related to edema may be warranted but is secondary to ineffective tissue perfusion.
A client is diagnosed with deep vein thrombosis (DVT). Which nursing diagnosis should receive highest priority at this time? A. Impaired gas exchange related to increased blood flow B. Excess fluid volume related to peripheral vascular disease C. Risk for injury related to edema D.Ineffective peripheral tissue perfusion related to venous congestion
Correct response: Constant, intense back pain and falling blood pressure Explanation: Indications of a rupturing abdominal aortic aneurysm include constant, intense back pain; falling blood pressure; and 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? A. Constant, intense back pain and falling blood pressure B. Constant, intense headache and falling blood pressure C. Higher than normal blood pressure and falling hematocrit D.Slow heart rate and high blood pressure
Correct response: Raynaud's disease Explanation: Raynaud's disease results from reduced blood flow to the extremities when exposed to cold or stress. It's commonly associated with connective tissue disorders such as SLE. Signs and symptoms include pallor, coldness, numbness, throbbing pain, and cyanosis. Peripheral vascular disease results from a reduced blood supply to the tissues. It occurs in the arterial or venous system. Build-up of plaque in the vessels or changes in the vessels results in reduced blood flow, causing pain, edema, and hair loss in the affected extremity. Arterial occlusive disease is the obstruction or narrowing of the lumen of the aorta and its major branches that interrupts blood flow to the legs and feet, causing pain and coolness. Buerger's disease is an inflammatory, nonatheromatous occlusive disease that causes segmental lesions and subsequent thrombus formation in arteries, resulting i
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? A. Peripheral vascular disease B. Raynaud's disease C. Arterial occlusive diseases D. Buerger's disease
Correct response: 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 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.
Correct response: "I will need to stop smoking because the nicotine causes less blood to flow to my hands and feet." Explanation: The use of tobacco products may be one of the most important risk factors in the development of atherosclerotic lesions. Nicotine in tobacco decreases blood flow to the extremities and increases heart rate and blood pressure by stimulating the sympathetic nervous system. This causes vasoconstriction, thereby decreasing arterial blood flow. It also increases the risk of clot formation by increasing the aggregation of platelets.
A community health nurse teaches a group of seniors about modifiable risk factors that contribute to the development of peripheral arterial disease (PAD). The nurse knows that the teaching was effective based on which of the following statements? A."I will need to stop smoking because the nicotine causes less blood to flow to my hands and feet." B. "I will need to increase the amount of green leafy vegetables I eat to lower my cholesterol levels." C. "The older I get the higher my risk for peripheral arterial disease gets." D. "Since my family is from Italy, I have a higher risk of developing peripheral arterial disease."
Correct response: 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.
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. History of increased aspirin use B. Recent pelvic surgery C. An active daily walking program D. A history of diabetes mellitus
Correct response: Venous insufficiency Explanation: Symptoms of venous insufficiency include present pedal pulses, edema, pigmentation in gater 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.
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 gater 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. Arterial insufficiency B. Venous insufficiency C. Neither venous nor arterial insufficiency D. Trauma
Correct response: 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.
A nurse and physician are preparing to visit a hospitalized client with perepheral 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 can walk about 50 feet before getting pain in the right lower leg. 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's legs awaken him during the night with itching.
Correct response: 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 nurse is assessing a client's right lower leg, which is wrapped with an elastic bandage. Which signs and symptoms suggest circulatory impairment? A. Numbness, cool skin temperature, and pallor B. Swelling, warm skin temperature, and drainage C. Numbness, warm skin temperature, and redness D. Redness, cool skin temperature, and swelling
Correct response: forcing blood into the deep venous system. Explanation: 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 nurse is instructing a client about using antiembolism stockings. Antiembolism stockings help prevent deep vein thrombosis (DVT) by: A. encouraging ambulation to prevent pooling of blood. B. providing warmth to the extremity. C. elevating the extremity to prevent pooling of blood. D. forcing blood into the deep venous system.
Correct response: "Shoes made of synthetic material are best for my feet." Explanation: The client should wear leather shoes with an extra-depth toebox. Synthetic shoes do not allow air to circulate.
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. "Shoes made of synthetic material are best for my feet." B. "It is important to apply sunscreen to the top of my feet when wearing sandals." C. "I should apply powder daily because my feet perspire." D. "I can use lamb's wool between my toes if necessary."
Correct response: "I have my wife look at the soles of my feet each day." Explanation: A client with peripheral vascular disease should examine his feet daily for redness, dryness, or cuts. If a client isn't able to do this examination on his own, then a caregiver or family member should help him. A client with peripheral vascular disease should avoid hot tubs because decreased sensation in the feet may make him unable to tell if the water is too hot. The client should always wear shoes or slippers on his feet when he is out of bed to help minimize trauma to the feet. Any type of nicotine, whether it's from cigarettes or smokeless tobacco, can cause vasoconstriction and further decrease blood supply to the extremities.
A nurse is reviewing self-care measures for a client with peripheral vascular disease. Which statement indicates proper self-care measures? A. "I like to soak my feet in the hot tub every day." B. "I walk only to the mailbox in my bare feet." C. "I stopped smoking and use only chewing tobacco." D. "I have my wife look at the soles of my feet each day."
Correct response: Epinephrine Explanation: Infrequently, a patient may have an immediate or delayed allergic reaction to the iodine contained in the contrast agent used in angiography. Manifestations include dyspnea, nausea and vomiting, sweating, tachycardia, and numbness of the extremities. Any such reaction must be reported to the interventionalist at once; treatment may include the administration of epinephrine, antihistamines, or corticosteroids.
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? A. Metoprolol (Lopressor) B. Epinephrine C. Hydrocortisone (Solu-Cortef) D. Cimetidine (Tagamet)
Correct response: Stabilizing heart rate and blood pressure and easing anxiety Explanation: 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.
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? A. Decreasing blood pressure and increasing mobility B. Increasing blood pressure and reducing mobility C. Stabilizing heart rate and blood pressure and easing anxiety D. Increasing blood pressure and monitoring fluid intake and output
Correct response: abdominal aorta, just below the renal arteries. Explanation: About 75% of aneurysms occur in the abdominal aorta, just below the renal arteries (Debakey type I aneurysms). Debakey type II aneurysms occur in the aortic arch around the ascending and descending aorta, whereas Debakey type III aneurysms occur in the descending aorta, beyond the subclavian arteries.
The most common site of aneurysm formation is in the: A. abdominal aorta, just below the renal arteries. B. ascending aorta, around the aortic arch. C. descending aorta, beyond the subclavian arteries. D. aortic arch, around the ascending and descending aorta.
Correct response: "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 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."
Correct response: Avoid situations that contribute to ischemic episodes. Explanation: 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. Reporting changes in the usual pattern of chest pain or avoiding fatty foods and exercise does not help the client to avoid an attack; it is more contributory for clients with CAD. In addition, the nurse advises clients to avoid over-the-counter decongestants.
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? A. Report changes in the usual pattern of chest pain. B. Avoid situations that contribute to ischemic episodes. C. Avoid fatty foods and exercise. D. Take over-the-counter decongestants.
Correct response: 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.
The nurse is caring for a patient with venous insufficiency. What should the nurse assess the patient's lower extremities for? A. Rudor B. Cellulitis C. Dermatitis D. Ulceration
Correct response: 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.
The nurse performing an assessment on a patient who has arterial insufficiency of the legs and an ulcer on the left great toe would expect to find which of the following characteristics? A. Diminished or absent pulses B. Superficial ulcer C. Aching, cramping pain D. Pulses are present, may be difficult to palpate
Correct response: 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.
The nurse performing an assessment on a patient who has arterial insufficiency of the legs and an ulcer on the left great toe would expect to find which of the following characteristics? A. Diminished or absent pulses B. Superficial ulcer C. Aching, cramping pain D. Pulses are present, may be difficult to palpate
Correct response: Vasospasm Explanation: 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. Patients with arterial insufficiency who smoke or chew tobacco must be fully informed of the effects of nicotine on circulation and be encouraged to stop.
The nurse teaches the patient with peripheral vascular disease (PVD) to refrain from smoking because nicotine causes which of the following? A. Vasospasm B. Slowed heart rate C. Depression of the cough reflex D. Diuresis
Correct response: 0.50 Explanation: 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.
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
Correct response: Contrast phlebography Explanation: Also known as venography, contrast phlebography involves injecting a radiopaque contrast agent into the venous system. If a thrombus exists, the x-ray image reveals an unfilled segment of vein in an otherwise completely filled 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.
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 which of the following? A. Air plethysmography B. Contrast phlebography C. Lymphangiography D. Lymphoscintigraphy
Correct response: Anterior surface of the foot near the ankle joint. Explanation: The dorsalis pedis pulse can be palpated on the dorsal surface of the foot distal to the major prominence of the navicular bone. Refer to Figure 18-3 in the text.
To assess the dorsalis pedis artery, the nurse would use the tips of three fingers and apply light pressure to the: A. Inside of the ankle just above the heel. B. Exterior surface of the foot near the heel. C. Outside of the foot just below the heel. D. Anterior surface of the foot near the ankle joint.
Correct response: Ulcers and infection in the edematous area Explanation: In a patient with lymphedema, the tissue nutrition is impaired from the stagnation of lymphatic fluid, leading to ulcers and infection in the edematous area. Later, the skin also appears thickened, rough, and discolored. Scarring does not occur in patients with lymphedema, and cyanosis is a bluish discoloration of the skin and mucous membranes.
What are the symptoms a nurse should assess for in a patient with lymphedema as a result of impaired nutrition to the tissue? A.Loose and wrinkled skin B. Ulcers and infection in the edematous area C. Evident scarring D. Cyanosis
Correct response: Obesity Explanation: Obesity is a risk factor for DVT and PE related to venous stasis. Trauma, pacing wires, and surgery are related to endothelial damage as a risk factor for DCAT and PE.
Which of the following are risk factors related to venous stasis for DVT and pulmonary embolism? A. Trauma B. Pacing wires C. Obesity D. Surgery
Correct response: Thoracic area Explanation: 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.
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
Correct response: Border of the ulcer is irregular Explanation: The border of an ulcer caused by arterial insufficiency is circular. Superficial venous insufficiency ulcers cause minimal pain. The base of a venous insufficiency ulcer shows beefy red to yellow fibrinous color. Venous insufficiency ulcers are usually superficial.
Which of the following observations regarding ulcer formation on the patient's lower extremity indicates that the ulcer is a result of venous insufficiency? A. Border of the ulcer is irregular B. Is very painful to the patient, even though superficial C. Base is pale to black D. Is deep, involving the joint space
Correct response: Atherosclerosis Explanation: Atherosclerosis is the most common cause of peripheral arterial problems in the older adult. Therefore, options A, B, and D are incorrect.
You are presenting a workshop at the senior citizens center about how the changes of aging predisposes clients to vascular occlusive disorders. What would you name as the most common cause of peripheral arterial problems in the older adult? A. Aneurysm B. Coronary thrombosis C. Atherosclerosis D. Raynaud's disease
