Nokea
The nurse is caring for a 72-year-old patient who is in cardiac rehabilitation following heart surgery. The patient has been walking on a regular basis for about a week and walks for 15 minutes 3 times a day. The patient states that he is having a cramp-like pain in the legs every time he walks and that the pain gets better when I rest. The patients care plan should address what problem?
- A. Decreased mobility related to VTE
- B. Acute pain related to intermittent claudication
- C. Decreased mobility related to venous insufficiency
- D. Acute pain related to vasculitis
Correct Answer: B
Rationale: Intermittent claudication presents as a muscular, cramp-type pain in the extremities consistently reproduced with the same degree of exercise or activity and relieved by rest. Patients with peripheral arterial insufficiency often complain of intermittent claudication due to a lack of oxygen to muscle tissue. Venous insufficiency presents as a disorder of venous blood reflux and does not present with cramp-type pain with exercise. Vasculitis is an inflammation of the blood vessels and presents with weakness, fever, and fatigue, but does not present with cramp-type pain with exercise. The pain associated with VTE does not have this clinical presentation.
You may also like to solve these questions
A medical nurse has admitted four patients over the course of a 12-hour shift. For which patient would assessment of ankle-brachial index (ABI) be most clearly warranted?
- A. A patient who has peripheral edema secondary to chronic heart failure
- B. An older adult patient who has a diagnosis of unstable angina
- C. A patient with poorly controlled type 1 diabetes who is a smoker
- D. A patient who has community-acquired pneumonia and a history of COPD
Correct Answer: C
Rationale: Nurses should perform a baseline ABI on any patient with decreased pulses or any patient 50 years of age or older with a history of diabetes or smoking. The other answers do not apply.
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 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.
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.
The nurse caring for a patient with a leg ulcer has finished assessing the patient and is developing a problem list prior to writing a plan of care. What major nursing diagnosis might the care plan include?
- A. Risk for disuse syndrome
- B. Ineffective health maintenance
- C. Sedentary lifestyle
- D. Imbalanced nutrition: less than body requirements
Correct Answer: D
Rationale: Major nursing diagnoses for the patient with leg ulcers may include imbalanced nutrition: less than body requirements, related to increased need for nutrients that promote wound healing. Risk for disuse syndrome is a state in which an individual is at risk for deterioration of body systems owing to prescribed or unavoidable musculoskeletal inactivity. A leg ulcer will affect activity, but rarely to this degree. Leg ulcers are not necessarily a consequence of ineffective health maintenance or sedentary lifestyle.