Nokea
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.
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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 in a long-term care facility is caring for an 83-year-old woman who has a history of HF and peripheral arterial disease (PAD). At present the patient is unable to stand or ambulate. The nurse should implement measures to prevent what complication?
- A. Aoritis
- B. Deep vein thrombosis
- C. Thoracic aortic aneurysm
- D. Raynauds disease
Correct Answer: B
Rationale: Although the exact cause of venous thrombosis remains unclear, three factors, known as Virchows triad, are believed to play a significant role in its development: stasis of blood (venous stasis), vessel wall injury, and altered blood coagulation. In this womans case, she has venous stasis from immobility, vessel wall injury from PAD, and altered blood coagulation from HF. The cause of aoritis is unknown, but it has no direct connection to HF, PAD, or mobility issues. The greatest risk factors for thoracic aortic aneurysm are atherosclerosis and hypertension; there is no direct connection to HF, PAD, or mobility issues. Raynauds disease is a disorder that involves spasms of blood vessels and, again, no direct connection to HF, PAD, or mobility issues.
The triage nurse in the ED is assessing a patient who has presented with complaint of pain and swelling in her right lower leg. The patients pain became much worse last night and appeared along with fever, chills, and sweating. The patient states, I hit my leg on the car door 4 or 5 days ago and it has been sore ever since. The patient has a history of chronic venous insufficiency. What intervention should the nurse anticipate for this patient?
- A. Platelet transfusion to treat thrombocytopenia
- B. Warfarin to treat arterial insufficiency
- C. Antibiotics to treat cellulitis
- D. Heparin IV to treat VTE
Correct Answer: C
Rationale: Cellulitis is the most common infectious cause of limb swelling. The signs and symptoms include acute onset of swelling, localized redness, and pain; it is frequently associated with systemic signs of fever, chills, and sweating. The patient may be able to identify a trauma that accounts for the source of infection. Thrombocytopenia is a loss or decrease in platelets and increases a patients risk of bleeding; this problem would not cause these symptoms. Arterial insufficiency would present with ongoing pain related to activity. This patient does not have signs and symptoms of VTE.
A nurse has written a plan of care for a man diagnosed with peripheral arterial insufficiency. One of the nursing diagnoses in the care plan is altered peripheral tissue perfusion related to compromised circulation. What is the most appropriate intervention for this diagnosis?
- A. Elevate his legs and arms above his heart when resting.
- B. Encourage the patient to engage in a moderate amount of exercise.
- C. Encourage extended periods of sitting or standing.
- D. Discourage walking in order to limit pain.
Correct Answer: B
Rationale: The nursing diagnosis of altered peripheral tissue perfusion related to compromised circulation requires interventions that focus on improving circulation. Encouraging the patient to engage in a moderate amount of exercise serves to improve circulation. Elevating his legs and arms above his heart when resting would be passive and fails to promote circulation. Encouraging long periods of sitting or standing would further compromise circulation. The nurse should encourage, not discourage, walking to increase circulation and decrease pain.
An older adult patient has been treated for a venous ulcer and a plan is in place to prevent the occurrence of future ulcers. What should the nurse include in this plan?
- A. Use of supplementary oxygen to aid tissue oxygenation
- B. Daily use of normal saline compresses on the lower limbs
- C. Daily administration of prophylactic antibiotics
- D. A high-protein diet that is rich in vitamins
Correct Answer: D
Rationale: A diet that is high in protein, vitamins C and A, iron, and zinc is encouraged to promote healing and prevent future ulcers. Prophylactic antibiotics and saline compresses are not used to prevent ulcers. Oxygen supplementation does not prevent ulcer formation.