Nokea
A patient tells the health care provider about experiencing cold, numb fingers when running during the winter and is diagnosed with Raynaud's phenomenon. Based upon this diagnosis, the patient should be investigated for which of the following conditions?
- A. Hypertension
- B. Hyperlipidemia
- C. Autoimmune disorders
- D. Coronary artery disease
Correct Answer: C
Rationale: Secondary Raynaud's phenomenon may occur in conjunction with autoimmune diseases such as rheumatoid arthritis, and patients should be screened for autoimmune disorders. Raynaud's phenomenon is not associated with hyperlipidemia, hypertension, or coronary artery disease.
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The nurse is assessing a patient who has chronic peripheral artery disease (PAD) of the legs and an ulcer on the left great toe. Which of the following findings should the nurse expect?
- A. A positive Homans' sign
- B. Swollen, dry, scaly ankles
- C. Prolonged capillary refill in all the toes
- D. A large amount of drainage from the ulcer
Correct Answer: C
Rationale: Capillary refill is prolonged in PAD because of the slower and decreased blood flow to the periphery. The other listed clinical manifestations are consistent with chronic venous disease.
The nurse is caring for a patient with chronic atrial fibrillation who develops sudden severe pain, pulselessness, pallor, and coolness in the left leg. Which of the following actions should the nurse implement first?
- A. Elevate the left leg on a pillow.
- B. Apply an elastic wrap to the leg.
- C. Assist the patient in gently exercising the leg.
- D. Notify the health care provider.
Correct Answer: D
Rationale: The patient's history and clinical manifestations are consistent with acute arterial occlusion. Clinical manifestations of acute arterial ischemia include the 'six Ps': pain, pallor, paralysis, pulselessness, paresthesia, and poikilothermia (adaptation of the limb to the environmental temperature most often cool). Without immediate intervention, ischemia may progress quickly to tissue necrosis and gangrene within a few hours. If the nurse detects these signs, the nurse should immediately notify the health care provider. Elevating the leg or applying an elastic wrap will further compromise blood flow to the leg. Exercise will increase oxygen demand for the tissues of the leg.
A patient is admitted to the hospital with a diagnosis of chronic venous insufficiency. Which of the following patient statements is most consistent with this diagnosis?
- A. I can't get my shoes on at the end of the day.
- B. I can never seem to get my feet warm enough.
- C. I wake up during the night because my legs hurt.
- D. I have burning leg pains after I walk three blocks.
Correct Answer: A
Rationale: Because the edema associated with venous insufficiency increases when the patient has been standing, shoes will feel tighter at the end of the day. The other patient statements are characteristic of peripheral artery disease (PAD).
The nurse is discussing risk factor modification for a patient who has a 4-cm abdominal aortic aneurysm. The nurse should focus patient teaching on which of the following risk factors?
- A. Male gender
- B. Marfan syndrome
- C. Abdominal trauma history
- D. Uncontrolled hypertension
Correct Answer: D
Rationale: All of the factors contribute to the patient's risk, but only the hypertension can potentially be modified to decrease the patient's risk for further expansion of the aneurysm.
Which of the following actions by a nurse who is administering fondaparinux to a patient with venous thromboembolism (VTE) indicates that more education about the medication is needed?
- A. The nurse avoids rubbing the injection site after giving the medication.
- B. The nurse injects the medication into the abdominal subcutaneous tissue.
- C. The nurse fails to assess the partial thromboplastin time (PTT) before administration of the medication.
- D. The nurse ejects the air bubble in the syringe before administering the medication.
Correct Answer: D
Rationale: The air bubble is not ejected before giving fondaparinux. The other actions by the nurse are appropriate.