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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.
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When assessing venous disease in a patients lower extremities, the nurse knows that what test will most likely be ordered?
- A. Duplex ultrasonography
- B. Echocardiography
- C. Positron emission tomography (PET)
- D. Radiography
Correct Answer: A
Rationale: Duplex ultrasound may be used to determine the level and extent of venous disease as well as its chronicity. Radiographs (x-rays), PET scanning, and echocardiography are never used for this purpose as they do not allow visualization of blood flow.
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.
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 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.
A nurse in the rehabilitation unit is caring for an older adult patient who is in cardiac rehabilitation following an MI. The nurses plan of care calls for the patient to walk for 10 minutes 3 times a day. The patient questions the relationship between walking and heart function. How should the nurse best reply?
- A. The arteries in your legs constrict when you walk and allow the blood to move faster and with more pressure on the tissue.
- B. Walking increases your heart rate and blood pressure. Therefore your heart is under less stress.
- C. Walking helps your heart adjust to your new arteries and helps build your self-esteem.
- D. When you walk, the muscles in your legs contract and pump the blood in your veins back toward your heart, which allows more blood to return to your heart.
Correct Answer: D
Rationale: Veins, unlike arteries, are equipped with valves that allow blood to move against the force of gravity. The legs have one-way bicuspid valves that prevent blood from seeping backward as it moves forward by the muscles in our legs pressing on the veins as we walk and increasing venous return. Leg arteries do constrict when walking, which allows the blood to move faster and with more pressure on the tissue, but the greater concern is increasing the flow of venous blood to the heart. Walking increases, not decreases, the heart pumping ability, which increases heart rate and blood pressure and the hearts ability to manage stress. Walking does help the heart adjust to new arteries and may enhance self-esteem, but the patient had an MIthere are no new arteries.