Nokea
The prevention of VTE is an important part of the nursing care of high-risk patients. When providing patient teaching for these high-risk patients, the nurse should advise lifestyle changes, including which of the following?
- A. High-protein diet
- B. Weight loss
- C. Regular exercise
- D. Smoking cessation
- E. Calcium and vitamin D supplementation
Correct Answer: B,C,D
Rationale: Patients at risk for VTE should be advised to make lifestyle changes, as appropriate, which may include weight loss, smoking cessation, and regular exercise. Increased protein intake and supplementation with vitamin D and calcium do not address the main risk factors for VTE.
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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.
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.
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 clinic nurse is caring for a 57-year-old client who reports experiencing leg pain whenever she walks several blocks. The patient has type 1 diabetes and has smoked a pack of cigarettes every day for the past 40 years. The physician diagnoses intermittent claudication. The nurse should provide what instruction about long-term care to the client?
- A. Be sure to practice meticulous foot care.
- B. Consider cutting down on your smoking.
- C. Reduce your activity level to accommodate your limitations.
- D. Try to make sure you eat enough protein.
Correct Answer: A
Rationale: The patient with peripheral vascular disease or diabetes should receive education or reinforcement about skin and foot care. Intermittent claudication and other chronic peripheral vascular diseases reduce oxygenation to the feet, making them susceptible to injury and poor healing; therefore, meticulous foot care is essential. The patient should stop smokingnot just cut downbecause nicotine is a vasoconstrictor. Daily walking benefits the patient with intermittent claudication. Increased protein intake will not alleviate the patients symptoms.
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.