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A nurse is caring for a patient with peripheral vascular disease (PVD). The patient complains of burning and tingling of the hands and feet and cannot tolerate touch of any kind. Which of the following is the most likely explanation for these symptoms?
- A. Inadequate tissue perfusion leading to nerve damage.
- B. Fluid overload leading to compression of nerve tissue.
- C. Sensation distortion due to psychiatric disturbance.
- D. Inflammation of the skin on the hands and feet.
Correct Answer: A
Rationale: Patients with the peripheral vascular disease often sustain nerve damage as a result of inadequate tissue perfusion. Ischemic rest pain is more worrisome; it refers to pain in the extremity that is due to a combination of PVD and inadequate perfusion. Ischemic rest pain often is exacerbated by poor cardiac output. The condition is often partially or fully relieved by placing the extremity in a dependent position, so that perfusion is enhanced by the effects of gravity.
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When assessing a patient who has just arrived after an automobile accident, the emergency department nurse notes tachycardia and absent breath sounds over the right lung. For which intervention will the nurse prepare the patient?
- A. Emergency pericardiocentesis
- B. Stabilization of the chest wall with tape
- C. Administration of an inhaled bronchodilator
- D. Insertion of a chest tube with a chest drainage system
Correct Answer: D
Rationale: The patient's history and absent breath sounds suggest a right-sided pneumothorax or hemothorax, which will require treatment with a chest tube and drainage. Emergency pericardiocentesis is not indicated as the patient's symptoms are not suggestive of cardiac tamponade. Stabilization of the chest wall with tape would not address the underlying issue of a potential pneumothorax or hemothorax. Administration of an inhaled bronchodilator is not appropriate in this scenario as the patient is not exhibiting signs of asthma or bronchoconstriction. Therefore, the correct intervention for this patient is the insertion of a chest tube with a chest drainage system to address the potential pneumothorax or hemothorax.
Claudication is a well-known effect of peripheral vascular disease. Which of the following facts about claudication is correct? Select the one that doesn't apply:
- A. It results when oxygen demand is greater than oxygen supply.
- B. It is characterized by pain that often occurs during rest.
- C. It is a result of tissue hypoxia.
- D. It is characterized by cramping and weakness.
Correct Answer: D
Rationale: Claudication is a symptom of peripheral vascular disease where there is an inadequate supply of oxygen to the muscles due to reduced blood flow. This mismatch between oxygen demand and supply leads to tissue hypoxia, resulting in cramping, weakness, and discomfort. Option D correctly states that claudication is characterized by cramping and weakness, making it the correct answer. Options A, B, and C are incorrect. Claudication occurs when oxygen demand exceeds supply, not the other way around as stated in Option A. Pain in claudication typically occurs with activity, not at rest as mentioned in Option B. While tissue hypoxia is a consequence of claudication, it is not the primary cause, making Option C incorrect.
A patient with acute dyspnea is scheduled for a spiral computed tomography (CT) scan. Which information obtained by the nurse is a priority to communicate to the health care provider before the CT?
- A. Allergy to shellfish
- B. Apical pulse of 104
- C. Respiratory rate of 30
- D. Oxygen saturation of 90%
Correct Answer: A
Rationale: Because iodine-based contrast media is used during a spiral CT, the patient may need to have the CT scan without contrast or be premedicated before injection of the contrast media. The increased pulse, low oxygen saturation, and tachypnea all indicate a need for further assessment or intervention but do not indicate a need to modify the CT procedure.
A patient with acute shortness of breath is admitted to the hospital. Which action should the nurse take during the initial assessment of the patient?
- A. Ask the patient to lie down to complete a full physical assessment.
- B. Briefly ask specific questions about this episode of respiratory distress.
- C. Complete the admission database to check for allergies before treatment.
- D. Delay the physical assessment to first complete pulmonary function tests.
Correct Answer: B
Rationale: When a patient presents with acute shortness of breath, the initial assessment should focus on gathering specific information relevant to the current episode of respiratory distress. A comprehensive health history or full physical examination can be deferred until the acute distress has been addressed. Asking specific questions helps determine the cause of the distress and guides appropriate treatment. While checking for allergies is important, completing the entire admission database is not a priority during the initial assessment. Likewise, delaying the physical assessment for pulmonary function tests is not recommended as the immediate focus should be on addressing the acute respiratory distress before ordering further diagnostic tests or interventions.
A patient with newly diagnosed lung cancer tells the nurse, 'I don't think I'm going to live to see my next birthday.' Which response by the nurse is best?
- A. Would you like to talk to the hospital chaplain about your feelings?
- B. Can you tell me what it is that makes you think you will die so soon?
- C. Are you afraid that the treatment for your cancer will not be effective?
- D. Do you think that taking an antidepressant medication would be helpful?
Correct Answer: B
Rationale: The nurse's initial response should be to collect more assessment data about the patient's statement. The answer beginning 'Can you tell me what it is' is the most open-ended question and will offer the best opportunity for obtaining more data. The answer beginning 'Are you afraid' implies that the patient thinks that the cancer will be immediately fatal, although the patient's statement may not be related to the cancer diagnosis. The remaining two answers offer interventions that may be helpful to the patient, but more assessment is needed to determine whether these interventions are appropriate.