HESI_Critical Care_Vascular Dz

A client presents with bilateral leg pain and cramping in the lower extremities. The client has a history of cardiovascular disease, diabetes, and varicose veins. To guide the assessment of the pain and cramping, the nurse should include which question when completing the initial assessment? 1. "Does walking for long periods of time increase your pain?" 2. "Does standing without moving decrease your pain?" 3. "Have you had your potassium level checked recently?" 4. "Have you had any broken bones in your lower extremities?"

1. "Does walking for long periods of time increase your pain?" Clients with a medical history of heart disease, hypertension, phlebitis, diabetes, or varicose veins often develop vascular related complications. The nurse should recognize that the relationship of symptoms to exercise will clarify whether the presenting problem is vascular or musculoskeletal. Pain caused by a vascular condition tends to increase with activity. Musculoskeletal pain is not usually relieved when exercise ends. Low potassium levels can cause cramping in the lower extremities, however, given the client's health history, vascular insufficiency should be suspected. Previously healed broken bones do not cause cramping and pain

A nurse is completing the admission assessment of a client with peripheral arterial disease. What assessments are consistent with this diagnosis? Select all that apply. 1. Absence of hair on the toes 2. Superficial ulcer with irregular edges 3. Pitting edema of the lower extremities 4. Reports of pain associated with exercising 5. Increased pigmentation of the medial malleolus area

1. Absence of hair on the toes 4. Reports of pain associated with exercising The absence of hair on the toes occurs because of diminished circulation. Reports of pain associated with exercising (intermittent claudication) are common because the increased need for oxygen leads to ischemia when arterial flow is impaired. A superficial ulcer with irregular edges is associated with venous insufficiency; the ulcer associated with arterial insufficiency is deep, well demarcated, and may be gangrenous. Pitting edema of the lower extremities is associated with venous insufficiency. Increased pigmentation of the medial and lateral malleolus areas is associated with venous insufficiency and occurs as a result of degeneration of red blood cells (RBCs) that leak into surrounding tissue.

When assessing the client with peripheral arterial disease, the nurse anticipates the presence of which clinical manifestations? Select all that apply. 1. Dependent rubor 2. Warm extremities 3. Ulcers on the toes 4. Thick, hardened skin 5. Delayed capillary refill

1. Dependent rubor 3. Ulcers on the toes 5. Delayed capillary refill Peripheral arterial disease affects arterial circulation and results in delayed and impaired circulation to the extremities. As a result, the extremities exhibit rubor while in the dependent position and pallor while elevated, ulcers on the feet and toes, cool skin, and capillary refill greater than three seconds. Warm extremities and thick, hardened skin occur in the presence of venous disease.

A client had a bypass graft because of an abdominal aortic aneurysm. Postoperative prescriptions include measurements of the client's abdominal girth. Which serious problem may be indicated by an increasing abdominal girth? 1. Graft leakage 2. Bowel puncture 3. Abdominal infection 4. Postoperative flatulence

1. Graft leakage During the first 24 hours after surgery, a sudden increase in abdominal girth most likely is graft related and needs to be investigated. Bowel puncture is a remote possibility but will present with classic signs (e.g., board-like abdomen, abdominal pain) other than increasing abdominal girth. It is too early for an infection to manifest signs and symptoms. It is too early for postoperative flatulence to occur.

A client with peripheral arterial insufficiency is scheduled for surgery. On admission, the client complains of discomfort and aches in the legs and feet. To safely position this client the nurse takes into consideration that the feet and legs should be: 1. Placed dependent to the torso 2. Dependent by using a fully extended knee gatch 3. Raised to a two pillow height above the buttocks 4. Elevated by raising the foot of the bed on blocks

1. Placed dependent to the torso Elevated by raising the foot of the bed on blocks Gravity will assist the flow of blood to the dependent legs and feet. An extended knee gatch keeps extremities horizontal, not dependent, and does not facilitate blood flow to the feet. Elevation impedes flow of arterial blood to the extremities; it facilitates venous return.

A nurse is caring for a client admitted with cardiovascular disease. During the assessment of the client's lower extremities, the nurse notes that the client has thin, shiny skin, decreased hair growth, and thickened toenails. The nurse understands that this may indicate: 1. Venous insufficiency 2. Arterial Insufficiency 3. Phlebitis 4. Lymphedema

2. Arterial Insufficiency Clients suffering from arterial insufficiency present with pale colored extremities when elevated and dusky red colored extremities when lowered. Lower extremities may also be cool to touch, pulses may be absent or mild, and skin may be shiny, thin, with decreased hair growth, and thickened nails. Clients suffering from venous insufficiency often have normal colored extremities, normal temperature, normal pulses, marked edema, and brown pigmentation around ankles. Phlebitis is an inflammation of a vein that occurs most often after trauma to the vessel wall, infection, and immobilization. Lymphedema is swelling in one or more extremities that is a direct result from impaired flow of the lymphatic system.

A nurse is teaching a group of clients with peripheral vascular disease about a smoking cessation program. Which physiologic effect of nicotine should the nurse explain to the group? 1. Constriction of the superficial vessels dilates the deep vessels. 2. Constriction of the peripheral vessels increases the force of flow. 3. Dilation of the superficial vessels causes constriction of collateral circulation. 4. Dilation of the peripheral vessels causes reflex constriction of visceral vessels.

2. Constriction of the peripheral vessels increases the force of flow. Constriction of the peripheral blood vessels and the resulting increase in blood pressure impair circulation and limit the amount of oxygen being delivered to body cells, particularly in the extremities. Nicotine constricts all peripheral vessels, not just superficial ones. Its primary action is vasoconstriction; it will not dilate deep vessels. Nicotine constricts rather than dilates peripheral vessels.

While a client with an abdominal aortic aneurysm is being prepared for surgery, the client complains of feeling lightheaded. The client is pale and has a rapid pulse. The nurse concludes that the client is: 1. Hyperventilating. 2. Going into shock. 3. Experiencing anxiety. 4. Developing an infection.

2. Going into shock. The clinical findings are early signs of shock. Shock ensues rapidly after a ruptured aortic aneurysm because of profound hemorrhage. The nurse can observe hyperventilation by watching the client's breathing patterns; rapid respirations are expected with hyperventilation. There are no data that indicate that the client is hyperventilating. Anxiety usually is not associated with lightheadedness unless there is accompanying hyperventilation. The signs and symptoms are not inclusive enough to indicate infection; there is no indication of fever.

On the morning of surgery a client is admitted for resection of an abdominal aortic aneurysm. While awaiting surgery, the client suddenly develops symptoms of shock. The nurse should: 1. Prepare for blood transfusions 2. Notify the surgeon immediately 3. Give the client nothing by mouth (NPO) 4. Administer the prescribed sedative

2. Notify the surgeon immediately Immediate surgical intervention to clamp the aorta is necessary for survival; the aneurysm has ruptured. Preparing for blood transfusions may be done eventually, but notifying the surgeon is the priority. The client is already NPO. Sedatives mask important signs and symptoms.

A client with a 40-year history of drinking two alcoholic beverages and smoking two packs of cigarettes daily comes to the outpatient clinic with an ischemic left foot. It is determined that the cause is arterial insufficiency. The nurse concludes that the pain in the client's foot is a result of inadequate blood supply, which may be diminished further by: 1. Drinking alcohol 2. Lowering the limb 3. Smoking cigarettes 4. Consuming excessive fluid

3. Smoking cigarettes Nicotine causes vasoconstriction and spasm of the peripheral arteries. Alcohol may stimulate dilation of blood vessels. Lowering the limb enhances flow of blood into the foot by gravity but does not support the return flow of blood. Consuming excessive fluid will decrease the viscosity of blood, possibly preventing the formation of thrombi.

A nurse is obtaining an admission history for a client who is scheduled for surgery to repair a ruptured abdominal aneurysm. Which type of shock is this client at risk for developing? 1. Vasogenic 2. Neurogenic 3. Cardiogenic 4. Hypovolemic

4. Hypovolemic Hypovolemic shock occurs when an abdominal aneurysm ruptures. Shock ensues because fluid volume becomes depleted as the heart continues to pump blood out of the ruptured vessel. Vasogenic shock results from the action of humoral or toxic substances directly on the blood vessels, causing vasodilation. Neurogenic shock results from decreased neuromuscular tone, which reduces vasoconstriction. Cardiogenic shock results from a decrease in cardiac output.

What client response indicates to the nurse that a vasodilator medication is effective? 1. Pulse rate decreases from 110 to 75 2. Absence of adventitious breath sounds 3. Increase in the daily amount of urine produced 4. Blood pressure changes from 154/90 to 126/72

Vasodilation will lower the blood pressure. The pulse rate is not decreased and may increase. Breath sounds are not directly affected by vasodilation, although vasodilator medications can decrease preload and afterload, which could indirectly affect breath sounds in heart failure. The urine output is not affected immediately, although control of blood pressure can help preserve renal function over time.