Nokea
A 79-year-old man is admitted to the medical unit with digital gangrene. The man states that his problems first began when he stubbed his toe going to the bathroom in the dark. In addition to this trauma, the nurse should suspect that the patient has a history of what health problem?
- A. Raynauds phenomenon
- B. CAD
- C. Arterial insufficiency
- D. Varicose veins
Correct Answer: C
Rationale: Arterial insufficiency may result in gangrene of the toe (digital gangrene), which usually is caused by trauma. The toe is stubbed and then turns black. Raynauds, CAD and varicose veins are not the usual causes of digital gangrene in the elderly.
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The nurse is evaluating a patients diagnosis of arterial insufficiency with reference to the adequacy of the patients blood flow. On what physiological variables does adequate blood flow depend?
- A. Efficiency of heart as a pump
- B. Adequacy of circulating blood volume
- C. Ratio of platelets to red blood cells
- D. Size of red blood cells
- E. Patency and responsiveness of the blood vessels
Correct Answer: A,B,E
Rationale: Adequate blood flow depends on the efficiency of the heart as a pump, the patency and responsiveness of the blood vessels, and the adequacy of circulating blood volume. Adequacy of blood flow does not primarily depend on the size of red cells or their ratio to the number of platelets.
A nurse is admitting a 45-year-old man to the medical unit who has a history of PAD. While providing his health history, the patient reveals that he smokes about two packs of cigarettes a day, has a history of alcohol abuse, and does not exercise. What would be the priority health education for this patient?
- A. The lack of exercise, which is the main cause of PAD.
- B. The likelihood that heavy alcohol intake is a significant risk factor for PAD.
- C. Cigarettes contain nicotine, which is a powerful vasoconstrictor and may cause or aggravate PAD.
- D. Alcohol suppresses the immune system, creates high glucose levels, and may cause PAD.
Correct Answer: C
Rationale: Tobacco is powerful vasoconstrictor; its use with PAD is highly detrimental, and patients are strongly advised to stop using tobacco. Sedentary lifestyle is also a risk factor, but smoking is likely a more significant risk factor that the nurse should address. Alcohol use is less likely to cause PAD, although it carries numerous health risks.
A nurse is creating an education plan for a patient with venous insufficiency. What measure should the nurse include in the plan?
- A. Avoiding tight-fitting socks.
- B. Limit activity whenever possible.
- C. Sleep with legs in a dependent position.
- D. Avoid the use of pressure stockings.
Correct Answer: A
Rationale: Measures taken to prevent complications include avoiding tight-fitting socks and panty girdles; maintaining activities, such as walking, sleeping with legs elevated, and using pressure stockings. Not included in the teaching plan for venous insufficiency would be reducing activity, sleeping with legs dependent, and avoiding pressure stockings. Each of these actions exacerbates venous insufficiency.
An occupational health nurse is providing an educational event and has been asked by an administrative worker about the risk of varicose veins. What should the nurse suggest as a proactive preventative measure for varicose veins?
- A. Sit with crossed legs for a few minutes each hour to promote relaxation.
- B. Walk for several minutes every hour to promote circulation.
- C. Elevate the legs when tired.
- D. Wear snug-fitting ankle socks to decrease edema.
Correct Answer: B
Rationale: A proactive approach to preventing varicose veins would be to walk for several minutes every hour to promote circulation. Sitting with crossed legs may promote relaxation, but it is contraindicated for patients with, or at risk for, varicose veins. Elevating the legs only helps blood passively return to the heart and does not help maintain the competency of the valves in the veins. Wearing tight ankle socks is contraindicated for patients with, or at risk for, varicose veins; socks that are below the muscles of the calf do not promote venous return, the socks simply capture the blood and promote venous stasis.
A postsurgical patient has illuminated her call light to inform the nurse of a sudden onset of lower leg pain. On inspection, the nurse observes that the patients left leg is visibly swollen and reddened. What is the nurses most appropriate action?
- A. Administer a PRN dose of subcutaneous heparin.
- B. Inform the physician that the patient has signs and symptoms of VTE.
- C. Mobilize the patient promptly to dislodge any thrombi in the patients lower leg.
- D. Massage the patients lower leg to temporarily restore venous return.
Correct Answer: B
Rationale: VTE requires prompt medical follow-up. Heparin will not dissolve an established clot. Massaging the patients leg and mobilizing the patient would be contraindicated because they would dislodge the clot, possibly resulting in a pulmonary embolism.