Nokea
A patient comes to the walk-in clinic with complaints of pain in his foot following stepping on a roofing nail 4 days ago. The patient has a visible red streak running up his foot and ankle. What health problem should the nurse suspect?
- A. Cellulitis
- B. Local inflammation
- C. Elephantiasis
- D. Lymphangitis
Correct Answer: D
Rationale: Lymphangitis is an acute inflammation of the lymphatic channels. It arises most commonly from a focus of infection in an extremity. Usually, the infectious organism is hemolytic streptococcus. The characteristic red streaks that extend up the arm or the leg from an infected wound outline the course of the lymphatic vessels as they drain. Cellulitis is caused by bacteria, which cause a generalized edema in the subcutaneous tissues surrounding the affected area. Local inflammation would not present with red streaks in the lymphatic channels. Elephantiasis is transmitted by mosquitoes that carry parasitic worm larvae; the parasites obstruct the lymphatic channels and results in gross enlargement of the limbs.
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You are caring for a patient who is diagnosed with Raynauds phenomenon. The nurse should plan interventions to address what nursing diagnosis?
- A. Chronic pain
- B. Ineffective tissue perfusion
- C. Impaired skin integrity
- D. Risk for injury
Correct Answer: B
Rationale: Raynauds phenomenon is a form of intermittent arteriolar vasoconstriction resulting in inadequate tissue perfusion. This results in coldness, pain, and pallor of the fingertips or toes. Pain is typically intermittent and acute, not chronic, and skin integrity is rarely at risk. In most cases, the patient is not at a high risk for injury.
The nurse is caring for an acutely ill patient who is on anticoagulant therapy. The patient has a comorbidity of renal insufficiency. How will this patients renal status affect heparin therapy?
- A. Heparin is contraindicated in the treatment of this patient.
- B. Heparin may be administered subcutaneously, but not IV.
- C. Lower doses of heparin are required for this patient.
- D. Coumadin will be substituted for heparin.
Correct Answer: C
Rationale: If renal insufficiency exists, lower doses of heparin are required. Coumadin cannot be safely and effectively used as a substitute and there is no contraindication for IV administration.
The nurse has performed a thorough nursing assessment of the care of a patient with chronic leg ulcers. The nurses assessment should include which of the following components?
- A. Location and type of pain
- B. Apical heart rate
- C. Bilateral comparison of peripheral pulses
- D. Comparison of temperature in the patients legs
- E. Identification of mobility limitations
Correct Answer: A,C,D,E
Rationale: A careful nursing history and assessment are important. The extent and type of pain are carefully assessed, as are the appearance and temperature of the skin of both legs. The quality of all peripheral pulses is assessed, and the pulses in both legs are compared. Any limitation of mobility and activity that results from vascular insufficiency is identified. Not likely is there any direct indication for assessment of apical heart rate, although peripheral pulses must be assessed.
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.
When assessing venous disease in a patients lower extremities, the nurse knows that what test will most likely be ordered?
- A. Duplex ultrasonography
- B. Echocardiography
- C. Positron emission tomography (PET)
- D. Radiography
Correct Answer: A
Rationale: Duplex ultrasound may be used to determine the level and extent of venous disease as well as its chronicity. Radiographs (x-rays), PET scanning, and echocardiography are never used for this purpose as they do not allow visualization of blood flow.