Nokea
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.
You may also like to solve these questions
Graduated compression stockings have been prescribed to treat a patients venous insufficiency. What education should the nurse prioritize when introducing this intervention to the patient?
- A. The need to take anticoagulants concurrent with using compression stockings
- B. The need to wear the stockings on a one day on, one day off schedule
- C. The importance of wearing the stockings around the clock to ensure maximum benefit
- D. The importance of ensuring the stockings are applied evenly with no pressure points
Correct Answer: D
Rationale: Any type of stocking can inadvertently become a tourniquet if applied incorrectly (i.e., rolled tightly at the top). In such instances, the stockings produce rather than prevent stasis. For ambulatory patients, graduated compression stockings are removed at night and reapplied before the legs are lowered from the bed to the floor in the morning. They are used daily, not on alternating days. Anticoagulants are not always indicated in patients who are using compression stockings.
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.
A patient comes to the walk-in clinic with complaints of pain in his foot following stepping on a roofing nail 4 days ago. The patient has a visible red streak running up his foot and ankle. What health problem should the nurse suspect?
- A. Cellulitis
- B. Local inflammation
- C. Elephantiasis
- D. Lymphangitis
Correct Answer: D
Rationale: Lymphangitis is an acute inflammation of the lymphatic channels. It arises most commonly from a focus of infection in an extremity. Usually, the infectious organism is hemolytic streptococcus. The characteristic red streaks that extend up the arm or the leg from an infected wound outline the course of the lymphatic vessels as they drain. Cellulitis is caused by bacteria, which cause a generalized edema in the subcutaneous tissues surrounding the affected area. Local inflammation would not present with red streaks in the lymphatic channels. Elephantiasis is transmitted by mosquitoes that carry parasitic worm larvae; the parasites obstruct the lymphatic channels and results in gross enlargement of the limbs.
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.
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.