Brunner Ch 30: Assessment and Management of Patients With Vascular Disorders and Problems of Peripheral Circulation Flashcards
The nurse is taking a health history of a new patient. The patient reports experiencing pain in his left lower leg and foot when walking. This pain is relieved with rest. The nurse notes that the left lower leg is slightly edematous and is hairless. When planning this patients subsequent care, the nurse should most likely address what health problem? A) Coronary artery disease (CAD) B) Intermittent claudication C) Arterial embolus D) Raynauds disease
Ans: B
Feedback:
A muscular, cramp-type pain in the extremities consistently reproduced with the same degree of exercise or activity and relieved by rest is experienced by patients with peripheral arterial insufficiency. Referred to as intermittent claudication, this pain is caused by the inability of the arterial system to provide adequate blood flow to the tissues in the face of increased demands for nutrients and oxygen during exercise. The nurse would not suspect the patient has CAD, arterial embolus, or Raynauds disease; none of these health problems produce this cluster of signs and symptoms.
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.
ANS: B
Feedback:
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.
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
Ans: B
Feedback:
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 admitting a 32-year-old woman to the presurgical unit. The nurse learns during the admission assessment that the patient takes oral contraceptives. Consequently, the nurses postoperative plan of care should include what intervention?
A) Early ambulation and leg exercises
B) Cessation of the oral contraceptives until 3 weeks postoperative
C) Doppler ultrasound of peripheral circulation twice daily
D) Dependent positioning of the patients extremities when at rest
Ans: A
Feedback:
Oral contraceptive use increases blood coagulability; with bed rest, the patient may be at increased risk of developing deep vein thrombosis. Leg exercises and early ambulation are among the interventions that address this risk. Assessment of peripheral circulation is important, but Doppler ultrasound may not be necessary to obtain these data. Dependent positioning increases the risk of venous thromboembolism (VTE). Contraceptives are not normally discontinued to address the risk of VTE in the short term.
A nurse is creating an education plan for a patient with venous insufficiency. What measure should the nurse include in the plan?
A) Avoiding tight-fitting socks.
B) Limit activity whenever possible.
C) Sleep with legs in a dependent position.
D) Avoid the use of pressure stockings.
Ans: A
Feedback:
Measures taken to prevent complications include avoiding tight-fitting socks and panty girdles; maintaining activities, such as walking, sleeping with legs elevated, and using pressure stockings. Not included in the teaching plan for venous insufficiency would be reducing activity, sleeping with legs dependent, and avoiding pressure stockings. Each of these actions exacerbates venous insufficiency.
The nurse is caring for a patient with a large venous leg ulcer. What intervention should the nurse implement to promote healing and prevent infection?
A) Provide a high-calorie, high-protein diet.
B) Apply a clean occlusive dressing once daily and whenever soiled.
C) Irrigate the wound with hydrogen peroxide once daily.
D) Apply an antibiotic ointment on the surrounding skin with each dressing change.
Ans: A
Feedback:
Wound healing is highly dependent on adequate nutrition. The diet should be sufficiently high in calories and protein. Antibiotic ointments are not normally used on the skin surrounding a leg ulcer and
occlusive dressings can exacerbate impaired blood flow. Hydrogen peroxide is not normally used because it can damage granulation tissue.
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
ANS: A
Feedback:
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.
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.
ANS: B
Feedback:
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
ANS: D
Feedback:
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 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
ANS: C
Feedback:
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.
A nurse in a long-term care facility is caring for an 83-year-old woman who has a history of HF and peripheral arterial disease (PAD). At present the patient is unable to stand or ambulate. The nurse should implement measures to prevent what complication? A. Aoritis B. Deep vein thrombosis C. Thoracic aortic aneurysm D. Raynauds disease
ANS: B
Feedback:
Although the exact cause of venous thrombosis remains unclear, three factors, known as Virchows triad, are believed to play a significant role in its development: stasis of blood (venous stasis), vessel wall injury, and altered blood coagulation. In this womans case, she has venous stasis from immobility, vessel wall injury from PAD, and altered blood coagulation from HF. The cause of aoritis is unknown, but it has no direct connection to HF, PAD, or mobility issues. The greatest risk factors for thoracic aortic aneurysm are atherosclerosis and hypertension; there is no direct connection to HF, PAD, or mobility issues. Raynauds disease is a disorder that involves spasms of blood vessels and, again, no direct connection to HF, PAD, or mobility issues.
A nurse is admitting a 45-year-old man to the medical unit who has a history of PAD. While providing his health history, the patient reveals that he smokes about two packs of cigarettes a day, has a history of alcohol abuse, and does not exercise. What would be the priority health education for this patient?
A. The lack of exercise, which is the main cause of PAD.
B. The likelihood that heavy alcohol intake is a significant risk factor for PAD.
C. Cigarettes contain nicotine, which is a powerful vasoconstrictor and may cause or aggravate PAD.
D. Alcohol suppresses the immune system, creates high glucose levels, and may cause PAD.
ANS: C
Feedback:
Tobacco is powerful vasoconstrictor; its use with PAD is highly detrimental, and patients are strongly advised to stop using tobacco. Sedentary lifestyle is also a risk factor, but smoking is likely a more significant risk factor that the nurse should address. Alcohol use is less likely to cause PAD, although it carries numerous health risks.
A nurse has written a plan of care for a man diagnosed with peripheral arterial insufficiency. One of the nursing diagnoses in the care plan is altered peripheral tissue perfusion related to compromised circulation. What is the most appropriate intervention for this diagnosis?
A. Elevate his legs and arms above his heart when resting.
B. Encourage the patient to engage in a moderate amount of exercise.
C. Encourage extended periods of sitting or standing.
D. Discourage walking in order to limit pain.
ANS: B
Feedback:
The nursing diagnosis of altered peripheral tissue perfusion related to compromised circulation requires interventions that focus on improving circulation. Encouraging the patient to engage in a moderate amount of exercise serves to improve circulation. Elevating his legs and arms above his heart when resting would be passive and fails to promote circulation. Encouraging long periods of sitting or standing would further compromise circulation. The nurse should encourage, not discourage, walking to increase circulation and decrease pain.
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
ANS: B
Feedback:
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.
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.
ANS: D
Feedback:
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.
The nurse is caring for a patient who is admitted to the medical unit for the treatment of a venous ulcer in the area of her lateral malleolus that has been unresponsive to treatment. What is the nurse most likely to find during an assessment of this patients wound? A. Hemorrhage B. Heavy exudate C. Deep wound bed D. Pale-colored wound bed
ANS: B
Feedback:
Venous ulcerations in the area of the medial or lateral malleolus (gaiter area) are typically large, superficial, and highly exudative. Venous hypertension causes extravasation of blood, which discolors the area of the wound bed. Bleeding is not normally present.