Exam 3 - Chapter 18 Patients With Vascular Disorders and Problems of Peripheral Circulation
A patient has an ulcer on the medial malleolus. The ulcer is shallow with irregular edges. The wound base is red. Wound drainage is also present. What type of ulcer is this based on the scenario's description? A. venous ulcer B. arterial ulcer C. diabetic ulcer The answer is A. These findings are associated with a venous ulcer.
A. venous ulcer
Which is a characteristic of arterial insufficiency? Diminished or absent pulses Superficial ulcer Aching, cramping pain Pulses are present but may be difficult to palpate
Diminished or absent pulses 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.
A nurse is reviewing self-care measures for a client with peripheral vascular disease. Which statement indicates proper self-care measures? "I like to soak my feet in the hot tub every day." "I walk only to the mailbox in my bare feet." "I stopped smoking and use only chewing tobacco." "I have my wife look at the soles of my feet each day."
"I have my wife look at the soles of my feet each day." A 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 community health nurse teaches a group of older adults 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 statement? "I will need to stop smoking because the nicotine causes less blood to flow to my hands and feet." "I will need to increase the amount of green leafy vegetables I eat to lower my cholesterol levels." "The older I get the higher my risk for peripheral arterial disease gets." "Because my family is from Italy, I have a higher risk of developing peripheral arterial disease."
"I will need to stop smoking because the nicotine causes less blood to flow to my hands and feet." 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 client admitted to the medical-surgical unit with a venous thromboembolism (VTE) is started on enoxaparin and warfarin. The client asks the nurse why two medications are needed. Which response by the nurse is accurate? "Administration of two anticoagulants decreases the risk of recurrent venous thrombosis." "Enoxaparin will dissolve the clot, and warfarin will prevent any more clots from occurring." "The enoxaparin will work immediately, but the warfarin takes several days to achieve its full effect." "Because of the potential for a pulmonary embolism, it is important for you to take at least two anticoagulants."
"The enoxaparin will work immediately, but the warfarin takes several days to achieve its full effect." 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).
A patient who developed a deep vein thrombosis (DVT) is being treated with unfractionated heparin. The hospital's protocol for this treatment specifies analysis of the patient's activated partial thromboplastin time (aPTT) every 6 hours. When reviewing the patient's aPTT levels, the nurse should be aware that the desired levels for this patient will be: 60% to 70% of the normal reference range Slightly below or equal to the normal reference range Within normal reference range 1.5 to 2.5 times the normal reference range
1.5 to 2.5 times the normal reference range For patients with a DVT, heparin is in the effective, or therapeutic, range when the aPTT is 1.5 times to 2.5 times the baseline control.
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? Diminished or absent pulses Superficial ulcer Aching, cramping pain Pulses that are present but difficult to palpate
Diminished or absent pulses 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.
A client with venous insufficiency asks the nurse what they can do to decrease their risk of complications. What advice should the nurse provide to clients with venous insufficiency? Elevate the legs periodically for at least an hour. Avoid foods with iodine. Elevate the legs periodically for at least 15 to 20 minutes. Refrain from sexual activity for a week.
Elevate the legs periodically for at least 15 to 20 minutes. 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.
Which observation regarding ulcer formation on the client's lower extremity indicates to the nurse that the ulcer is a result of venous insufficiency? Large and superficial Though superficial, is very painful Base is pale to black Is deep, involving the joint space
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.
When caring for a patient with leg ulcers, the positioning of the legs depends on whether the patient's ulcer is arterial or venous in origin. How should the nurse position a patient who has leg ulcers that are venous in origin? Keep the patient's legs flat without the knees raised. Keep the patient's knees at a 45-degree angle. Elevate the patient's lower extremities. Hang the patient's legs over the side of the bed
Elevate the patient's lower extremities. Positioning of the legs depends on whether the ulcer is of arterial or venous origin. If there is venous insufficiency, dependent edema can be avoided by elevating the lower extremities. Bending the knees, keeping the legs flat, and dangling the patient's legs may exacerbate the condition.
Your patient has severe peripheral venous disease. During the head-to-toe nursing assessment, you would expect to find what skin characteristics of the lower extremities? Select all that apply: A. Thick, tough B. Thin, scaly C. Hairless D. Brown pigmented
A. Thick, tough D. Brown pigmented This is commonly found in severe peripheral venous disease. Options B and C are found in peripheral ARTERIAL disease.
You're assessing a patient's health history for peripheral vascular disease. What signs and symptoms reported by the patient would indicate the patient may be experiencing peripheral arterial disease? Select all that apply: A. "I often wake up at night with leg pain and have to dangle my leg out of the bed to ease the pain." B. "If I stand or sit too long my legs start to feel heavy and achy." C. "It hurts to elevate my legs." D. "Sometimes when I'm walking my legs start to cramp and tingle to the point where I can't walk until the pain goes away."
A. "I often wake up at night with leg pain and have to dangle my leg out of the bed to ease the pain." C. "It hurts to elevate my legs." D. "Sometimes when I'm walking my legs start to cramp and tin Peripheral arterial disease occurs when there is impediment of blood flow to the lower extremities (hence the lower extremities are being deprived of blood flow and this causes pain). The pain most commonly occurs at night and can wake up the patient. It is known as "rest pain". This occurs because when the legs are horizontal the blood flow is compromised and it causes pain...therefore the patient will report they dangle the leg off the bed to help ease the pain (the dependent position (dangling) will help blood flow down to the extremity). In addition, it hurts to elevate the legs (again because this further compromises blood flow). Option B occurs in peripheral venous disease. Option C is known as intermittent claudication and is a HALLMARK sign and symptom in PAD.
You're assessing a patient's health history for peripheral vascular disease. What signs and symptoms reported by the patient would indicate the patient may be experiencing peripheral arterial disease? Select all that apply:* A. "I often wake up at night with leg pain and have to dangle my leg out of the bed to ease the pain." B. "If I stand or sit too long my legs start to feel heavy and achy." C. "It hurts to elevate my legs." D. "Sometimes when I'm walking my legs start to cramp and tingle to the point where I can't walk until the pain goes away."
A. "I often wake up at night with leg pain and have to dangle my leg out of the bed to ease the pain." D. "Sometimes when I'm walking my legs start to cramp and tingle to the point where I can't walk until the pain goes away."
Select below all the characteristics that can present with an arterial ulcer: A. Found on the lateral malleolus, dorsum of foot, or end of toes B. Found on the medial malleolus or medial part of lower leg C. Deep, round, defined edges and has a "punched out" appearance D. Minimal drainage E. Edematous F. Brown pigmented skin surrounding the ulcer G. Wound base is pale
A. Found on the lateral malleolus, dorsum of foot, or end of toes C. Deep, round, defined edges and has a "punched out" appearance D. Minimal drainage G. Wound base is pale Arterial ulcers have very little blood flow to them so they will be pale (little granulation) and have little (if any) drainage. They will be deep, round, and have a "punched out" appearance. They are most commonly found on the lateral malleolus, dorsum of foot, or end of toes.
A patient is diagnosed with Raynaud's Disease. Which explanations below most accurately describe this condition? Select all that apply:* A. Raynaud's Disease is triggered by cold temperatures or stress. B. Raynaud's Disease occurs due to a vasospasm of the peripheral veins. C. Raynaud's Disease affects the toes, fingers, and sometimes the ears and nose. D. Raynaud's Disease is prevented by glucose control.
A. Raynaud's Disease is triggered by cold temperatures or stress. C. Raynaud's Disease affects the toes, fingers, and sometimes the ears and nose. Raynaud's Disease occurs when vasospasm of peripheral arteries occurs. It mainly affects the fingers and toes (it can also affect the ears/nose). It is triggered by exposure to cold or during stress. It can be prevented by keeping the toes, fingers, ears, and n
A patient is admitted to a special critical care unit for the treatment of an arterial thrombus. The nurse is aware that the preferred drug of choice for clot removal, unless contraindicated, would be: Alteplase. Reteplase. Urokinase. Streptokinase
Alteplase.
A patient with a diagnosis of deep vein thrombosis (DVT) is being treated with unfractionated heparin, which is being administered intravenously. The nurse who is providing care for this patient should consequently prioritize what assessments? Assessing the patient for internal or external hemorrhage Monitoring the patient's intake and output, and assessing for signs of fluid volume deficit Assessing the patient for adventitious lung sounds and assessing SaO2 levels Assessing the patient's pain levels
Assessing the patient for internal or external hemorrhage IV heparin administration creates a significant risk of bleeding. Consequently, assessments for hemorrhage would be prioritized over fluid balance, oxygenation, and pain, although each of these assessment domains is necessary.
The nurse is educating a patient with chronic venous insufficiency about prevention of complications related to the disorder. What should the nurse include in the information given to the patient? (Select all that apply.) Avoid constricting garments. Elevate the legs above the heart level for 30 minutes every 2 hours. Sit as much as possible to rest the valves in the legs. Sleep with the foot of the bed elevated about 6 inches. Sit on the side of the bed and dangle the feet.
Avoid constricting garments. Elevate the legs above the heart level for 30 minutes every 2 hours. Sleep with the foot of the bed elevated about 6 inches. Elevating the legs decreases edema, promotes venous return, and provides symptomatic relief. The legs should be elevated frequently throughout the day (at least 15 to 20 minutes four times daily). At night, the patient should sleep with the foot of the bed elevated about 15 cm (6 inches). Prolonged sitting or standing in one position is detrimental; walking should be encouraged. When sitting, the patient should avoid placing pressure on the popliteal spaces, as occurs when crossing the legs or sitting with the legs dangling over the side of the bed. Constricting garments, especially socks that are too tight at the top or that leave marks on the skin, should be avoided.
The nurse is caring for a client with Raynaud's disease. What are important instructions for a client who is diagnosed with this disease to prevent an attack? Report changes in the usual pattern of chest pain. Avoid situations that contribute to ischemic episodes. Avoid fatty foods and exercise. Take over-the-counter decongestants.
Avoid situations that contribute to ischemic episodes. Teaching for clients with Raynaud's disease and their family members is important. The nurse should instruct the clients to avoid situations that contribute to ischemic episodes. 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.
You're providing discharge teaching to a patient with peripheral arterial disease. Which statement by the patient requires you to re-educate the patient? A. "It is important I quit smoking." B. "To prevent my feet and legs from getting too cold at night, I will use a heating pad. C. "A walking program would be beneficial in treatment of my PAD." C. "I will avoid wearing tight socks or shoes."
B. "To prevent my feet and legs from getting too cold at night, I will use a heating pad. he patient should try to prevent the feet and legs from getting too cold because this causes vasoconstriction, which impedes blood flow further. Therefore, they should dress warmly with LOOSE layers. However, they should AVOID using heating pads because of the reduce of sensation from compromised blood flow. A walking program is a great way to prevent intermittent claudication, lower the cholesterol, and improve oxygen levels in the blood....which are all great ways of treating PAD.
A patient has severe peripheral venous disease. What important information below will the nurse provide to the patient about how to alleviate signs and symptoms associated with the disease? Select all that apply: A. Elevate the lower extremities below heart level frequently B. Application of compression stockings C. Limit long periods of standing and sitting D. Use the knee-flexed position while lying in bed
B. Application of compression stockings C. Limit long periods of standing and sitting The patient with peripheral VENOUS disease should elevate the lower extremities ABOVE heart level (this helps return blood to the heart and decrease swelling/pain), avoid crossing the legs (or the knee-flexed position) because this impedes blood flow, and limit long periods of standing and sitting (this limits blood return to the heart and increases swelling). In addition, the application of compression stockings is very beneficial in peripheral venous disease because it helps blood return to the heart and prevents the stasis of blood in the lower extremities.
Your patient has returned from a peripheral artery bypass for the treatment of peripheral arterial disease. The nurse will make it PRIORITY to? A. Assess the surgical site for excessive drainage B. Assess and grade lower extremity pulses bilaterally C. Apply compression stockings D. Elevate the lower extremity above heart level
B. Assess and grade lower extremity pulses bilaterally A peripheral artery bypass is performed to treat severe cases of PAD. The surgeon will "bypass" the blockage in the lower extremity and have blood flow re-routed around the blockage. This will provide blood flow back to the lower extremity. It is PRIORITY that the nurse assesses and grades the lower extremity pulses bilaterally frequently. If the pulses diminish or become absent the nurse should notify the physician immediately.
A client is recovering from surgical repair of a dissecting aortic aneurysm. Which assessment findings indicate possible bleeding or recurring dissection? Urine output of 15 ml/hour and 2+ hematuria Blood pressure of 82/40 mm Hg and heart rate of 125 beats/minute Urine output of 150 ml/hour and heart rate of 45 beats/minute Blood pressure of 82/40 mm Hg and heart rate of 45 beats/minute
Blood pressure of 82/40 mm Hg and heart rate of 125 beats/minute 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.
The MOST common cause of peripheral arterial disease is? A. Diabetes B. Deep vein thrombosis C. Atherosclerosis D. Pregnancy
C. Atherosclerosis
Your patient reports experiencing dull and achy sensations in the lower extremities. You note that the lower extremities have edema and brownish pigmentation. Pulses are present bilaterally and the extremities feel warm to the touch. To help alleviate the patient's symptoms, the nurse will position the lower extremities in the? A. Dependent position B. Horizontal position C. Elevated position above heart level D. Knee-flexed position
C. Elevated position above heart level Based on the signs and symptoms in the scenario above, the patient is experiencing peripheral VENOUS disease. The blood is stagnant (or static) in the lower extremities and can't flow back to the heart. Therefore, the patient is experiencing dull and achy sensations along with edema and brownish pigmentation. The nurse should place the patient's lower extremities in the elevated position above the heart to help facilitate blood return to the heart and alleviate the pain
A patient has an arterial ulcer on the lower extremity. What risk factors for peripheral arterial disease are in the patient's health history? Select all that apply: A. Pregnancy B. Being Female C. High Cholesterol D. Diabetes Mellitus E. Uncontrolled hypertension F. Varicose veins G. Smoking
C. High Cholesterol D. Diabetes Mellitus E. Uncontrolled hypertension G. Smoking High cholesterol, diabetes mellitus, uncontrolled hypertension, and smoking are risk factors for peripheral arterial disease (PAD). Pregnancy, being female, varicose veins are risk factors for peripheral venous disease.
Your patient is diagnosed with Buerger's Disease (thromboangiitis obliterans). The nurse will make it priority to educate the patient about implementing? A. Low fat diet B. Blood glucose control C. Smoking cessation D. Blood pressure control
C. Smoking cessation The most common cause of Buerger's Disease (thromboangiities obliterans) is tobacco usage (smoking). Buerger's Disease occurs when the blood vessels of the hands and feet become inflamed and clots form. The clots will block blood flow. The nurse should make it priority to educate the patient on smoking cessation.
The triage nurse in the emergency department (ED) is assessing a patient who presents complaining of pain and swelling in her right lower leg beginning last night along with fever, chills, and sweating. The patient states that she hit her leg on the car door 4 or 5 days ago, and it has been sore ever since. The patient has a history of chronic venous insufficiency. The nurse should suspect that this patient might have: Thrombocytopenia Arterial insufficiency Cellulitis Phlebothrombosis
Cellulitis Cellulitis is the most common infectious cause of limb swelling. The signs and symptoms include acute onset of swelling, localized redness, and pain; it is frequently associated with systemic signs of fever, chills, and sweating. The patient may be able to identify a trauma that accounts for the source of infection. Thrombocytopenia is a loss or decrease in platelets and increases a patient's risk of bleeding. Arterial insufficiency would present with pain related to activity. Phlebothrombosis presents with the similar signs and symptoms but is usually associated with mobility limitations. As well, the patient would not be able to identify a trauma that accounts for the source of infection.
A health care provider wants a cross-sectional image of the abdomen to evaluate the degree of stenosis in a patient's left common iliac artery. The nurse knows to prepare the patient for which of the following? Doppler ultrasound Magnetic resonance angiography (MRA) Angiography Computed tomography angiography (CTA)
Computed tomography angiography (CTA) A CTA is used to visualize arteries and veins and help assess for stenosis and occlusion.
Your patient has severe peripheral arterial disease. When the lower extremities are elevated you would expect them to appear _______________ and, when they are in the dependent position you would expect them to appear _________________. Fill in the blanks: A. cyanotic; rubor B. rubor; pallor C. cyanotic, pallor D. pallor; rubor
D. pallor; rubor In severe PAD, if the lower extremities are elevated they will turn pale (pallor). However, if they are in the dependent position (dangling) they will appear rubor (red and warm...this occurs due to inflammation of the vessels).
A patient is having an angiography to detect the presence of an aneurysm. After the contrast is administered by the interventionist, the patient begins to complain of nausea and difficulty breathing. What medication is a priority to administer at this time? Metoprolol (Lopressor) Epinephrine Hydrocortisone (Solu-Cortef) Cimetidine (Tagamet)
Epinephrine 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.
Which statement is accurate regarding Raynaud disease? The disease generally affects the client trilaterally. It affects more than two digits on each hand or foot. It is most common in men 16 to 40 years of age. Episodes may be triggered by unusual sensitivity to cold.
Episodes may be triggered by unusual sensitivity to cold. 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.
Peripheral venous disease can occur due to narrowing of the valves in the veins of the lower extremities. True False
False Peripheral venous disease can occur due to overstretched valves of the veins (NOT narrowed) in the lower extremities. In addition, it can occur when the veins become damaged.
A patient with diabetes is being treated for a wound on the lower extremity that has been present for 30 days. What option for treatment is available to increase diffusion of oxygen to the hypoxic wound? Surgical debridement Enzymatic debridement Hyperbaric oxygen Vacuum-assisted closure device
Hyperbaric oxygen 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? Within 12 hours Within the first 24 hours In 2 days In 3 to 5 days
In 3 to 5 days Oral anticoagulants, such as warfarin, are monitored by the PT or the INR. Because the full anticoagulant effect of warfarin is delayed for 3 to 5 days, it is usually administered concurrently with heparin until desired anticoagulation has been achieved (i.e., when the PT is 1.5 to 2 times normal or the INR is 2.0 to 3.0) (Holbrook et al., 2012).
Which sign or symptom suggests that a client's abdominal aortic aneurysm is extending? Increased abdominal and back pain Decreased pulse rate and blood pressure Retrosternal back pain radiating to the left arm Elevated blood pressure and rapid respirations
Increased abdominal and back pain
Which of the following is the hallmark symptom for peripheral arterial disease (PAD) in the lower extremity? Intermittent claudication Acute limb ischemia Dizziness Vertigo
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. 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.
A client is diagnosed with peripheral arterial disease. Review of the client's chart shows an ankle-brachial index (ABI) on the right of 0.45. This indicates that the right foot has which of the following? Moderate to severe arterial insufficiency No arterial insufficiency Very mild arterial insufficiency Tissue loss to that foot
Moderate to severe arterial insufficiency Normal people without arterial insufficiency have an ABI of about 1.0. Those with an ABI of 0.95 to 0.5 have mild to moderate arterial insufficiency. Those with an ABI of less than 0.50 have ischemic rest pain. Those with tissue loss have severe ischemia and an ABI of 0.25 or less.
A nurse is assessing a client's right lower leg, which is wrapped with an elastic bandage. Which signs and symptoms suggest circulatory impairment? Numbness, cool skin temperature, and pallor Swelling, warm skin temperature, and drainage Numbness, warm skin temperature, and redness Redness, cool skin temperature, and swelling
Numbness, cool skin temperature, and pallor 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 with Raynaud's disease complains of cold and numbness in the fingers. Which of the following would the nurse identify as an early sign of vasoconstriction? Cyanosis Gangrene Pallor Clubbing of the fingers
Pallor Pallor is the initial symptom in Raynaud's followed by cyanosis and aching pain. Gangrene can occur with persistent attacks and interference of blood flow. Clubbing of the fingers is a symptom associated with chronic oxygen deprivation to the distal phalanges.
A client has been diagnosed with peripheral arterial occlusive disease. Which of the following instructions is appropriate for the nurse to give the client for promoting circulation to the extremities? Keep the extremities elevated slightly. Participate in a regular walking program. Use a heating pad to promote warmth. Massage the calf muscles if pain occurs.
Participate in a regular walking program. 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 patient complains of a "stabbing pain and a burning sensation" in his left foot. The nurse notices that the foot is a lighter color than the rest of the skin. The artery that the nurse suspects is occluded would be the: Internal iliac. Common femoral. Popliteal. Posterior tibial.
Posterior tibial. 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 client with systemic lupus erythematosus (SLE) complains that his hands become pale, blue, and painful when exposed to the cold. What disease should the nurse cite as an explanation for these signs and symptoms? Peripheral vascular disease Raynaud's disease Arterial occlusive diseases Buerger's disease
Raynaud's disease 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 in decreased blood flow to the feet and legs.
A 61-year-old man has a longstanding history of peripheral artery disease that has progressed in recent months to acute limb ischemia (ALI). As a result, he has just undergone bilateral arterial bypass grafts and is postoperative day 1. The nurse's most recent assessment reveals that the patient's left foot is cold to touch and dusky in appearance with nonpalpable peripheral pulses. How should the nurse respond to this assessment finding? Report the finding to the surgeon immediately. Encourage the patient to perform light activity and assist with range of motion exercises. Place a warm compress on the patient's foot to stimulate circulation. Administer a dose of the patient's prescribed anticoagulant.
Report the finding to the surgeon immediately. Inadequate circulation following a bypass graft is a serious situation that may require emergency surgical intervention; these findings should be reported immediately. This is a priority over encouraging activity or applying warmth. Administration of anticoagulants is not a relevant intervention in this situation.
A nurse is admitting a new client with a deep vein thrombosis in her left leg. During the admission process, which information provided by the client would be a contraindication to anticoagulant therapy? Scheduled eye surgery in 1 week A cerebral vascular bleed 10 years ago Three vaginal births, the most recent 18 months ago Diet that includes many green, leafy vegetables every day
Scheduled eye surgery in 1 week
A woman has sought care from her primary care provider, stating, "The front of my foot aches constantly these days, and it's gotten so bad that it keeps me up at night." The nurse should recognize that this patient may be experiencing the symptoms of: Lymphangitis Deep vein thrombosis (DVT) Raynaud's disease Severe arterial insufficiency
Severe arterial insufficiency Persistent pain in 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 presentation is not typical of lymphangitis, DVT, or Raynaud's disease.
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? Decreasing blood pressure and increasing mobility Increasing blood pressure and reducing mobility Stabilizing heart rate and blood pressure and easing anxiety Increasing blood pressure and monitoring fluid intake and output
Stabilizing heart rate and blood pressure and easing anxiety 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.
When being assessed by her new nurse practitioner, a woman states that she has had Raynaud's disease for many years, a problem that occasionally affects her quality of life. When performing health education surrounding this problem, what should the nurse emphasize? Teaching the woman about atherosclerosis and its role in Raynaud's disease Teaching the woman about the correct use of anticoagulants Helping the woman identify and avoid the specific triggers of her problem Teaching the woman the signs and symptoms of deep vein thrombosis
Teaching the woman about atherosclerosis and its role in Raynaud's disease With appropriate patient teaching and lifestyle modifications, Raynaud's disease is generally benign and self-limiting. The patient is instructed to avoid the stimuli (e.g., cold, tobacco) that provoke vasoconstriction. Raynaud's is not caused by atherosclerosis, and it is not a risk factor for DVT. Anticoagulants do not address the signs, symptoms, or etiology of the disease.
Which of the following is accurate regarding the effects of nicotine and tobacco smoke on the body? Select all that apply. Causes vasospasm Reduces circulation to the extremities Impairs transport and cellular use of oxygen Increases blood viscosity Decreases blood viscosity
causes vasospasm Reduces circulation to the extremities Impairs transport and cellular use of oxygen Increases blood viscosity Nicotine from tobacco products causes vasospasm and can dramatically reduce circulation to the extremities. Tobacco smoke also impairs transport and cellular use of oxygen and increases blood viscosity.
True or False: Peripheral arterial disease leads to a decrease in rich oxygenated blood being delivered to the lower extremities, which leads to ischemia and necrosis of skin tissue. True False
True
What symptoms should the nurse assess for in a client with lymphedema as a result of impaired nutrition to the tissue? Loose and wrinkled skin Ulcers and infection in the edematous area Evident scaring Cyanosis
Ulcers and infection in the edematous area 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 home health nurse is seeing an elderly male client for the first time. During the physical assessment of the skin on the lower legs, the nurse notes edema, brown pigmentation in the gaiter area, pedal pulses, and a few irregularly shaped ulcers around the ankles. From these findings, the nurse knows that the client has a problem with peripheral circulation. Which of the following does the nurse suspect? Arterial insufficiency Venous insufficiency Neither venous nor arterial insufficiency Trauma
Venous insufficiency Symptoms of venous insufficiency include present pedal pulses, edema, pigmentation in gaiter area, and a reddish blue color. Ulcers caused by venous insufficiency will be irregular in shape and usually located around the ankles or the anterior tibial area. Characteristics of arterial insufficiency ulcers include location at the tips of the toes, great pain, and circular shape with a pale to black ulcer base.
A community health nurse is providing an educational event at the local seniors' center. The topic the nurse is speaking about is varicose veins. What would the nurse suggest as proactive preventative measure for varicose veins? Sitting with crossed legs to promote relaxation Walking for several minutes every hour to promote circulation Elevating the legs when tired Wearing tight ankle socks to decrease edema
Walking for several minutes every hour to promote circulation
The term for a diagnostic test that involves injection of a contrast media into the venous system through a dorsal vein in the foot is air plethysmography. contrast phlebography. lymphangiography. lymphoscintigraphy.
contrast phlebography. 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 most important reason for a nurse to encourage a client with peripheral vascular disease to initiate a walking program is that this form of exercise: reduces stress. aids in weight reduction. increases high-density lipoprotein (HDL) level. decreases venous congestion.
decreases venous congestion. Regular walking is the best way to decrease venous congestion because using the leg muscles as a pump helps return blood to the heart. 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.
To check for arterial insufficiency when a client is in a supine position, the nurse should elevate the extremity at a 45-degree angle and then have the client sit up. The nurse suspects arterial insufficiency if the assessment reveals: elevational rubor. no rubor for 10 seconds after the maneuver. elevational pallor. a 30-second filling time for the veins.
elevational pallor. If arterial insufficiency is present, elevation of the limb would yield a pallor from the lack of circulation. Rubor on elevation and increased venous filling time would suggest venous problems secondary to venous trapping and incompetent valves.
A nurse is instructing a client about using antiembolism stockings. Antiembolism stockings help prevent deep vein thrombosis (DVT) by: encouraging ambulation to prevent pooling of blood. providing warmth to the extremity. elevating the extremity to prevent pooling of blood. forcing blood into the deep venous system.
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 client with no known history of peripheral vascular disease comes to the emergency department complaining of sudden onset of lower leg pain. Inspection and palpation reveal absent pulses; paresthesia; and a mottled, cyanotic, cold, and cadaverous left calf. While the physician determines the appropriate therapy, the nurse should: place a heating pad around the affected calf. elevate the affected leg as high as possible. keep the affected leg level or slightly dependent. shave the affected leg in anticipation of surgery.
keep the affected leg level or slightly dependent. While the physician makes treatment decisions, the nurse should maintain the client on bed rest, keeping the affected leg level or slightly dependent (to aid circulation) and protecting it from pressure and other trauma. Warming the leg with a heating pad (or chilling it with an ice pack) would further compromise tissue perfusion and increase injury to the leg. Elevating the leg would worsen tissue ischemia. Shaving an ischemic leg could cause accidental trauma from cuts or nicks.
