H26 Flashcards
The nurse is taking a health history of a new client who reports pain in the left lower leg
and foot when walking. This pain is relieved with rest, and the nurse observes that the left
lower leg is slightly edematous and is hairless. When planning this client’s care, the nurse
should most likely address which health problem?
A. Coronary artery disease (CAD)
B. Intermittent claudication
C. Arterial embolus
D. Raynaud disease
ANS: B
Rationale: 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 clients 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 client has CAD, arterial embolus, or Raynaud disease; none of
these health problems produce this cluster of signs and symptoms.
While assessing a client, the nurse notes that the client’s ankle-brachial index (ABI) of
the right leg is 0.40. How should the nurse best follow up this assessment finding?
A. Assess the client’s use of over-the-counter dietary supplements.
B. Implement interventions relevant to arterial narrowing.
C. Encourage the client to increase intake of foods high in vitamin K.
D. Adjust the client’s activity level to accommodate decreased coronary output.
ANS: 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 over-the-counter (OTC) medications are not likely causative.
The nurse is admitting a 32-year-old woman to the presurgical unit. The nurse learns
during the admission assessment that the client takes oral contraceptives. The nurse’s
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 client’s extremities when at rest
ANS: A
Rationale: Oral contraceptive use increases blood coagulability; with bed rest, the client
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 client with venous insufficiency. Which
measure should the nurse include in the plan?
A. Avoid normal stockings that are tight.
B. Limit activities, including walking.
C. Sleep with legs below heart level.
D. Refrain from using graduated compression stockings.
ANS: A
Rationale: 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 client 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. Abstain from wearing graduated compression stockings.
D. Apply an antibiotic ointment on the surrounding skin with each dressing change.
ANS: A
Rationale: 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.
Compression therapy should be implemented with venous ulcers but not arterial ulcers.
The nurse is caring for a client who is seeking care for signs and symptoms of
lymphedema. The nurse’s plan of care should prioritize which nursing diagnosis?
A. Risk for infection related to lower extremity swelling secondary to lymphedema
B. Disturbed body image related to lower extremity swelling secondary to
lymphedema
C. Ineffective health maintenance related to lower extremity swelling secondary to
lymphedema
D. Risk for deficient fluid volume related to lower extremity swelling secondary to
lymphedema
ANS: A
Rationale: Lymphedema, which is caused by accumulation of lymph in the tissues,
constitutes a significant risk for infection. The client’s body image is likely to be disturbed,
and the nurse should address this, but infection is a more significant threat to the client’s
physiologic 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. Which action should the nurse
suggest as a preventive 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
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 clients 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
clients 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 client comes to the walk-in clinic with reports of pain in the foot following stepping on
a roofing nail 4 days ago. The client has a visible red streak running up his foot and ankle.
Which health problem should the nurse suspect?
A. Cellulitis
B. Local inflammation
C. Elephantiasis
D. Lymphangitis
ANS: 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 triage nurse in the emergency department is assessing a client who reports pain
and swelling in the right lower leg. The client’s pain became much worse last night and
appeared along with fever, chills, and sweating. The client states, “I hit my leg on the car
door 4 or 5 days ago, and it has been sore ever since.” The client has a history of chronic
venous insufficiency. Which intervention should the nurse anticipate for this client?
A. Platelet transfusion to treat thrombocytopenia
B. Warfarin to treat arterial insufficiency
C. Antibiotics to treat cellulitis
D. Intravenous heparin to treat venous thromboembolism (VTE)
ANS: 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 client 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 client’s risk of bleeding; this problem would not
cause these symptoms. Arterial insufficiency would present with ongoing pain related to
activity. This client does not have signs and symptoms of VTE.
A nurse in a long-term care facility is caring for an 83-year-old client who has a
history of heart failure (HF) and peripheral arterial disease (PAD). At present, the client is
unable to stand or ambulate. The nurse should implement measures to prevent which
complication?
A. Aortitis
B. Deep vein thrombosis
C. Thoracic aortic aneurysm
D. Raynaud disease
Rationale: Although the exact cause of venous thrombosis remains unclear, three
factors, known as Virchow triad, are believed to play a significant role in its development:
stasis of blood (venous stasis), vessel wall injury, and altered blood coagulation. This
client has venous stasis from immobility, vessel wall injury from PAD, and altered blood
coagulation from HF. The cause of aortitis 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. Raynaud disease is a disorder that involves spasms of blood vessels and, again,
no direct connection to HF, PAD, or mobility issues.
A nurse has written a plan of care for a client diagnosed with peripheral arterial
insufficiency. One of the nursing diagnoses in the care plan is altered peripheral tissue
perfusion related to compromised circulation. Which intervention is the most appropriate
for this diagnosis?
A. Elevate the legs and arms above the heart when resting.
B. Encourage the client 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
Rationale: The nursing diagnosis of altered peripheral tissue perfusion related to
compromised circulation requires interventions that focus on improving circulation.
Encouraging the client to engage in a moderate amount of exercise serves to improve
circulation. Elevating the client’s legs and arms above the 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 planning care for a client with venous insufficiency. Which nursing
intervention would be appropriate for this client’s plan of care?
A. Elevate lower extremities.
B. Educate on decreased protein.
C. Apply compression only at night.
D. Teach frequent rest periods due to pain.
ANS: A
Rationale: Venous insufficiency is lack of blood flow back to the heart. Elevation of lower
extremities will assist the peripheral blood vessels in returning stasis of blood. Increased
protein should be taught. Compression therapy should be used but not only at night. Pain
is not usually assessed in clients with venous insufficiency but with arterial insufficiency.
A nurse in the rehabilitation unit is caring for an older adult client who is in cardiac
rehabilitation following an MI. The nurse’s plan of care calls for the client to walk for 10
minutes 3 times a day. The client 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
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’s pumping ability, which increases heart rate and blood pressure
and the heart’s ability to manage stress. Walking does help the heart adjust to new
arteries and may enhance self-esteem, but the client had an MI—there are no “new
arteries.”
The nurse is preparing to administer warfarin to a client with deep vein
thrombophlebitis. Which laboratory value would most clearly indicate that the client’s
warfarin is at therapeutic levels?
A. Partial thromboplastin time (PTT) within normal reference range
B. Prothrombin time (PT) 8 to 10 times the control
C. International normalized ratio (INR) between 2 and 3
D. Hematocrit of 32%
ANS: C
Rationale: The INR is most often used to determine whether warfarin is at a therapeutic
level; an INR of 2 to 3 is considered therapeutic. Warfarin is also considered to be at
therapeutic levels when the client’s PT is 1.5 to 2 times the control. Higher values indicate
increased risk of bleeding and hemorrhage, whereas lower values indicate increased
risk
of blood clot formation. Heparin, not warfarin, prolongs PTT. Hematocrit does not provide
information on the effectiveness of warfarin; however, a falling hematocrit in a client
taking warfarin may be a sign of hemorrhage.
The clinic nurse is caring for a 57-year-old client who reports experiencing leg pain
whenever walking several blocks. The client has type 1 diabetes and has smoked a pack
of cigarettes every day for the past 40 years. The health care provider diagnoses
intermittent claudication. The nurse should provide which 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.”
ANS: A
Rationale: The client 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
client should stop smoking—not just cut down—because nicotine is a vasoconstrictor.
Daily walking benefits the client with intermittent claudication. Increased protein intake
will not alleviate the client’s symptoms.
