Nokea
The nurse is providing teaching to a patient with a venous ulcer on the right lower leg. Which of the following patient statements indicates a need for further teaching?
- A. I will put on my support stockings before I get out of bed in the morning.
- B. I will take an antibiotic for a few days to prevent infection of the ulcer.
- C. I will eat more meat and other high-protein foods.
- D. I will apply a compression dressing every evening before I go to bed.
Correct Answer: B
Rationale: Compression of the leg is essential to healing of venous ulcers in patients with chronic venous insufficiency. High dietary intake of protein, rather than carbohydrates, is needed. Prophylactic antibiotics are not routinely used for venous ulcers. Moist environment dressings are used to hasten wound healing. Applying a compression dressing only in the evening is insufficient; it should be worn consistently to promote healing.
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A patient tells the health care provider about experiencing cold, numb fingers when running during the winter and is diagnosed with Raynaud's phenomenon. Based upon this diagnosis, the patient should be investigated for which of the following conditions?
- A. Hypertension
- B. Hyperlipidemia
- C. Autoimmune disorders
- D. Coronary artery disease
Correct Answer: C
Rationale: Secondary Raynaud's phenomenon may occur in conjunction with autoimmune diseases such as rheumatoid arthritis, and patients should be screened for autoimmune disorders. Raynaud's phenomenon is not associated with hyperlipidemia, hypertension, or coronary artery disease.
The nurse is caring for a patient with chronic atrial fibrillation who develops sudden severe pain, pulselessness, pallor, and coolness in the left leg. Which of the following actions should the nurse implement first?
- A. Elevate the left leg on a pillow.
- B. Apply an elastic wrap to the leg.
- C. Assist the patient in gently exercising the leg.
- D. Notify the health care provider.
Correct Answer: D
Rationale: The patient's history and clinical manifestations are consistent with acute arterial occlusion. Clinical manifestations of acute arterial ischemia include the 'six Ps': pain, pallor, paralysis, pulselessness, paresthesia, and poikilothermia (adaptation of the limb to the environmental temperature most often cool). Without immediate intervention, ischemia may progress quickly to tissue necrosis and gangrene within a few hours. If the nurse detects these signs, the nurse should immediately notify the health care provider. Elevating the leg or applying an elastic wrap will further compromise blood flow to the leg. Exercise will increase oxygen demand for the tissues of the leg.
The nurse is assessing a patient in the emergency department with a history of an abdominal aortic aneurysm with severe back pain and absent pedal pulses. Which of the following actions should the nurse take first?
- A. Obtain the blood pressure.
- B. Ask the patient about tobacco use.
- C. Draw blood for ordered laboratory testing.
- D. Assess for the presence of an abdominal bruit.
Correct Answer: A
Rationale: Since the patient appears to be experiencing aortic dissection, the nurse's first action should be to determine the hemodynamic status by assessing blood pressure. The other actions also may be done, but they will not provide information that will determine what interventions are needed immediately for this patient.
The nurse is discussing risk factor modification for a patient who has a 4-cm abdominal aortic aneurysm. The nurse should focus patient teaching on which of the following risk factors?
- A. Male gender
- B. Marfan syndrome
- C. Abdominal trauma history
- D. Uncontrolled hypertension
Correct Answer: D
Rationale: All of the factors contribute to the patient's risk, but only the hypertension can potentially be modified to decrease the patient's risk for further expansion of the aneurysm.
While working in the outpatient clinic, the nurse notes that the medical record states that a patient has intermittent claudication. Which of the following patient statements is consistent with this information?
- A. When I stand too long, my feet start to swell up.
- B. Sometimes I get tired when I climb a lot of stairs.
- C. My fingers hurt when I go outside in cold weather.
- D. My legs cramp whenever I walk more than a block.
Correct Answer: D
Rationale: Cramping that is precipitated by a consistent level of exercise is descriptive of intermittent claudication. Finger pain associated with cold weather is typical of Raynaud's phenomenon. Fatigue that occurs sometimes with exercise is not typical of intermittent claudication, which is reproducible. Swelling associated with prolonged standing is typical of venous disease.