Nokea
The nurse is caring for a client who is post-varicose vein surgery. The nurse would include which teaching measure(s)? Select all that apply.
- A. Exercise
- B. Cool compresses
- C. Elastic stockings
- D. Lower the extremities
- E. Stand rather than sit
- F. Take warm showers in the morning
Correct Answer: A,C
Rationale: Movement/exercise and use of elastic stocking aid in venous return. Cool compresses can cause vasoconstriction, which can diminish arterial blood flow. Elevation of legs can be helpful in aiding venous return. Standing or sitting for prolonged periods of time should be avoided. Showers in the morning can dilate blood vessels and contribute to venous congestion and edema.
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The nurse is caring for a client who is status postoperative from a vein stripping. What would the nurse monitor for in the client?
- A. Swelling in the inoperative leg
- B. Blood on the dressing on the inoperative leg
- C. Warm, pink toes in the inoperative leg
- D. Swelling in the operative leg
Correct Answer: D
Rationale: When the client returns from surgery with a gauze dressing covered by elastic roller bandages on the operative leg, the nurse monitors for swelling in the operative leg(s) and its effect on circulation.
Which nursing assessment finding(s) suggests increased risk for coronary artery disease? Select all that apply.
- A. Arcus senilis
- B. Pear-shaped body
- C. Plump ear lobes
- D. Xanthelasma
- E. Sensory loss
- F. Motor changes
Correct Answer: A,D
Rationale: Arcus senilis is the opaque ring seen around the cornea that results from deposit of fat granules, and xanthelasma is raised yellow plaque on the eyelids. Both of these findings are suggestive of lipid accumulation that can increase the risk of CAD. An apple-shaped body carries a higher risk. Diagonal creases in the earlobe have been suggestive of CAD. Sensory and motor changes are more associated with CVA than CAD.
The nurse is working with a client who has just been diagnosed with an aneurysm. What advice should the nurse provide to this client?
- A. Minimize bowel movements and coughing
- B. Avoid situations that contribute to ischemic episodes
- C. Avoid straining during bowel movements and coughing
- D. Wear wool socks and mittens during cold weather
Correct Answer: C
Rationale: The nurse advises the client with an aneurysm to avoid straining during bowel movements and coughing. Coughing and straining increase the risk of rupture. The client with Raynaud syndrome is asked to avoid situations that contribute to ischemic episodes and to wear wool socks and mittens during cold weather.
The nurse provides care to a menopausal client who states, 'I read a news article that says I am at risk for coronary vascular disease due to inflammation.' Which method should the nurse suggest to the client to aid in the prevention of inflammation that can lead to atherosclerosis?
- A. Addressing obesity
- B. Avoiding the use of caffeine
- C. Taking a daily multivitamin
- D. Drinking at least 2 liters of water a day
Correct Answer: A
Rationale: The 2019 ACC/AHA Guideline on the Primary Prevention of Coronary Vascular Disease (CVD) indicates a relationship between body fat and the production of inflammatory and thrombotic (clot-facilitating) proteins. This information suggests that decreasing obesity and body fat stores via exercise, dietary modification, or developing drugs that target proinflammatory proteins may reduce risk factors for heart disease. The risk for CVD accelerates for clients after menopause due to withdrawal of endogenous estradiol levels, which can worsen many traditional CVD risk factors, including body fat distribution. Avoiding the use of caffeine, using a multivitamin, and drinking at least 2 liters of water a day are not actions that will address the prevention of inflammation that can lead to atherosclerosis.
A client comes to the emergency department (ED) complaining of precordial chest pain. In describing the pain, the client describes it as pressure with a sudden onset. What disease process would the nurse suspect in this client?
- A. Coronary artery disease
- B. Raynaud syndrome
- C. Cardiogenic shock
- D. Venous occlusive disease
Correct Answer: A
Rationale: The classic symptom of CAD is chest pain (angina) or discomfort during activity or stress. Such pain or discomfort typically is manifested as sudden pain or pressure that may be centered over the heart (precordial) or under the sternum (substernal). Raynaud syndrome in the hands presents with symptoms of hands that are cold, blanched, and wet with perspiration. Cardiogenic shock is a complication of an MI. Venous occlusive disease occurs in the veins, not the arteries.