Nokea
The nurse is caring for a patient who returned from the tropics a few weeks ago and who sought care with signs and symptoms of lymphedema. The nurses plan of care should prioritize what nursing diagnosis?
- A. Risk for infection related to lymphedema
- B. Disturbed body image related to lymphedema
- C. Ineffective health maintenance related to lymphedema
- D. Risk for deficient fluid volume related to lymphedema
Correct Answer: A
Rationale: Lymphedema, which is caused by accumulation of lymph in the tissues, constitutes a significant risk for infection. The patients body image is likely to be disturbed, and the nurse should address this, but infection is a more significant threat to the patients physiological well-being. Lymphedema is unrelated to ineffective health maintenance and deficient fluid volume is not a significant risk.
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An occupational health nurse is providing an educational event and has been asked by an administrative worker about the risk of varicose veins. What should the nurse suggest as a proactive preventative measure for varicose veins?
- A. Sit with crossed legs for a few minutes each hour to promote relaxation.
- B. Walk for several minutes every hour to promote circulation.
- C. Elevate the legs when tired.
- D. Wear snug-fitting ankle socks to decrease edema.
Correct Answer: B
Rationale: A proactive approach to preventing varicose veins would be to walk for several minutes every hour to promote circulation. Sitting with crossed legs may promote relaxation, but it is contraindicated for patients with, or at risk for, varicose veins. Elevating the legs only helps blood passively return to the heart and does not help maintain the competency of the valves in the veins. Wearing tight ankle socks is contraindicated for patients with, or at risk for, varicose veins; socks that are below the muscles of the calf do not promote venous return, the socks simply capture the blood and promote venous stasis.
The nurse is providing care for a patient who has just been diagnosed with peripheral arterial occlusive disease (PAD). What assessment finding is most consistent with this diagnosis?
- A. Numbness and tingling in the distal extremities
- B. Unequal peripheral pulses between extremities
- C. Visible clubbing of the fingers and toes
- D. Reddened extremities with muscle atrophy
Correct Answer: B
Rationale: PAD assessment may manifest as unequal pulses between extremities, with the affected leg cooler and paler than the unaffected leg. Intermittent claudication is far more common than sensations of numbness and tingling. Clubbing and muscle atrophy are not associated with PAD.
The nurse is evaluating a patients diagnosis of arterial insufficiency with reference to the adequacy of the patients blood flow. On what physiological variables does adequate blood flow depend?
- A. Efficiency of heart as a pump
- B. Adequacy of circulating blood volume
- C. Ratio of platelets to red blood cells
- D. Size of red blood cells
- E. Patency and responsiveness of the blood vessels
Correct Answer: A,B,E
Rationale: Adequate blood flow depends on the efficiency of the heart as a pump, the patency and responsiveness of the blood vessels, and the adequacy of circulating blood volume. Adequacy of blood flow does not primarily depend on the size of red cells or their ratio to the number of platelets.
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.
While assessing a patient the nurse notes that the patients ankle-brachial index (ABI) of the right leg is 0.40 . How should the nurse best respond to this assessment finding?
- A. Assess the patients use of over-the-counter dietary supplements.
- B. Implement interventions relevant to arterial narrowing.
- C. Encourage the patient to increase intake of foods high in vitamin K.
- D. Adjust the patients activity level to accommodate decreased coronary output.
Correct Answer: B
Rationale: ABI is used to assess the degree of stenosis of peripheral arteries. An ABI of less than 1.0 indicates possible claudication of the peripheral arteries. It does not indicate inadequate coronary output. There is no direct indication for changes in vitamin K intake and OTC medications are not likely causative.