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The client comes to the clinic complaining of muscle cramping and pain in both legs when walking for short periods of time. Which medical term would the nurse document in the client's record?
- A. Peripheral vascular disease.
- B. Intermittent claudication.
- C. Deep vein thrombosis.
- D. Dependent rubor.
Correct Answer: B
Rationale: Muscle cramping/pain with walking (B) is intermittent claudication, a hallmark of arterial occlusive disease. PVD (A) is broader, DVT (C) causes swelling/pain at rest, and dependent rubor (D) is a skin color change.
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Which assessment data would the nurse expect to find in the client diagnosed with chronic venous insufficiency?
- A. Decreased pedal pulses.
- B. Cool skin temperature.
- C. Intermittent claudication.
- D. Brown discolored skin.
Correct Answer: D
Rationale: Brown discoloration (D) results from hemosiderin deposits in venous insufficiency. Decreased pulses (A) and claudication (C) are arterial, and cool skin (B) is not typical (skin is often warm).
The client is prescribed nitroglycerin for angina. Which instruction should the nurse include?
- A. Take it every day even if you feel well.
- B. Place the tablet under your tongue.
- C. Swallow the tablet with water.
- D. Apply it as a patch on your chest.
Correct Answer: B
Rationale: Sublingual nitroglycerin is placed under the tongue for rapid absorption to relieve angina.
Which assessment data would support that the client has a venous stasis ulcer?
- A. A superficial pink open area on the medial part of the ankle.
- B. A deep pale open area over the top side of the foot.
- C. A reddened blistered area on the heel of the foot.
- D. A necrotic gangrenous area on the dorsal side of the foot.
Correct Answer: A
Rationale: Venous stasis ulcers are superficial, pink, and medial (A) due to venous pooling. Deep/pale (B) or necrotic (D) ulcers suggest arterial insufficiency, and blisters (C) are unrelated.
The client presents to the outpatient clinic complaining of calf pain. The client reports returning from an airplane trip the previous day. Which should the nurse assess first?
- A. The nurse should auscultate the lung fields and heart sounds.
- B. The nurse should determine the length of the airplane trip.
- C. The nurse should determine if the client has had chest pain.
- D. The nurse should measure the calf and palpate the calf for warmth.
Correct Answer: C
Rationale: Calf pain post-flight suggests DVT; assessing for chest pain (C) rules out pulmonary embolism, a priority. Lung/heart sounds (A), trip length (B), and calf exam (D) follow.
The nurse is caring for clients on a surgical floor. Which client should be assessed first?
- A. The client who is four (4) days postoperative abdominal surgery and is complaining of left calf pain when ambulating.
- B. The client who is one (1) day postoperative hernia repair who has just been able to void 550 mL of clear amber urine.
- C. The client who is five (5) days postoperative open cholecystectomy who has a T-tube and is being discharged.
- D. The client who is 16 hours post-abdominal hysterectomy and is complaining of abdominal pain and is expelling flatus.
Correct Answer: A
Rationale: Calf pain post-surgery (A) suggests DVT, requiring immediate assessment. Normal voiding (B), discharge (C), and expected pain/flatus (D) are less urgent.