Integ Exam #2 Flashcards
Which modality is contraindicated for clean, granulating wounds?
- A. Pulsed Lavage
- B. Whirlpool Therapy
- C. Wound Irrigation
- D. Electrical Stimulation
- Correct: B. Whirlpool Therapy Whirlpool is contraindicated for clean, granulating wounds as it can disrupt healing tissue.
- Incorrect: A. Pulsed Lavage Pulsed lavage can be used for irrigation and is not contraindicated.
- Incorrect: C. Wound Irrigation Irrigation is suitable for clean wounds.
- Incorrect: D. Electrical Stimulation Electrical stimulation is indicated for granulating wounds.
What is the primary effect of pulsed lavage with suction?
- A. Thermal insulation
- B. Reduction of bioburden
- C. Pain management
- D. Enhance oxygen perfusion
- Correct: B. Reduction of bioburden Pulsed lavage removes necrotic tissue and debris, reducing bioburden.
- Incorrect: A. Thermal insulation Pulsed lavage does not provide thermal effects.
- Incorrect: C. Pain management Pain relief is not a primary effect of pulsed lavage.
- Incorrect: D. Enhance oxygen perfusion Oxygenation is improved by other modalities like hyperbaric oxygen therapy.
Which modality facilitates wound contraction and reduces bioburden using subatmospheric pressure?
- A. Negative Pressure Wound Therapy
- B. Pulsed Lavage
- C. Hyperbaric Oxygen Therapy
- D. Electrical Stimulation
- **Correct: A. Negative Pressure Wound ** Therapy NPWT applies subatmospheric pressure, promoting granulation tissue and reducing bioburden.
- Incorrect: B. Pulsed Lavage Pulsed lavage uses irrigation, not subatmospheric pressure.
- Incorrect: C. Hyperbaric Oxygen Therapy HBO involves oxygenation, not pressure reduction.
- Incorrect: D. Electrical Stimulation Electrical stimulation does not involve subatmospheric pressure.
Which modality uses monophasic high-voltage pulsed current to stimulate healing?
- A. Electrical Stimulation
- B. Diathermy
- C. Ultrasound
- D. Negative Pressure Wound Therapy
- Correct: A. Electrical Stimulation Electrical stimulation uses high-voltage pulsed current to enhance wound healing.
- Incorrect: B. Diathermy Diathermy uses electromagnetic energy, not electrical currents.
- Incorrect: C. Ultrasound Ultrasound uses sound waves, not electrical currents.
- Incorrect: D. Negative Pressure Wound Therapy NPWT involves suction, not electrical stimulation.
What is a contraindication for using whirlpool therapy?
- A. Thick eschar
- B. Infected wounds
- C. Clean, granulating wounds
- D. Pain management
- Correct: C. Clean, granulating wounds Whirlpool therapy can disrupt healing in clean, granulating wounds.
- Incorrect: A. Thick eschar Whirlpool therapy can help soften eschar.
- Incorrect: B. Infected wounds Whirlpool therapy can aid in managing infected wounds.
- Incorrect: D. Pain management Pain management is a benefit, not a contraindication, of whirlpool therapy.
What is the primary purpose of ultraviolet C (UVC) therapy?
- A. Promote oxygen perfusion
- B. Reduce bacterial bioburden
- C. Manage granulation tissue
- D. Enhance scar pliability
- Correct: B. Reduce bacterial bioburden UVC therapy is primarily bactericidal and helps reduce bioburden in wounds.
- Incorrect: A. Promote oxygen perfusion Oxygenation is not a primary effect of UVC therapy.
- Incorrect: C. Manage granulation tissue UVC is not focused on granulation tissue.
- Incorrect: D. Enhance scar pliability Scar pliability is not a goal of UVC therapy.
Which therapy uses sound waves to facilitate wound debridement and healing?
- A. Pulsed Lavage
- B. Electrical Stimulation
- C. Ultrasound
- D. Diathermy
- Correct: C. Ultrasound Ultrasound uses sound waves to facilitate debridement and healing.
- Incorrect: A. Pulsed Lavage Pulsed lavage uses pressurized irrigation, not sound waves.
- Incorrect: B. Electrical Stimulation Electrical stimulation involves electrical currents, not sound waves.
- Incorrect: D. Diathermy Diathermy uses electromagnetic energy.
Which therapy is contraindicated for wounds with untreated osteomyelitis? * A. Negative Pressure Wound Therapy * B. Electrical Stimulation * C. Hyperbaric Oxygen Therapy * D. Wound Irrigation
- Correct: A. Negative Pressure Wound Therapy NPWT is contraindicated for wounds with untreated osteomyelitis. * Incorrect: B. Electrical Stimulation Electrical stimulation may be used with caution in osteomyelitis cases. * Incorrect: C. Hyperbaric Oxygen Therapy HBO is often used to treat osteomyelitis. * Incorrect: D. Wound Irrigation Wound irrigation is not contraindicated for osteomyelitis.
Which modality enhances healing by increasing oxygen concentration in the wound bed? * A. Hyperbaric Oxygen Therapy * B. Electrical Stimulation * C. Pulsed Lavage * D. Diathermy
- Correct: A. Hyperbaric Oxygen Therapy HBO increases oxygen levels in the wound bed to facilitate healing. * Incorrect: B. Electrical Stimulation Electrical stimulation does not directly increase oxygen concentration. * Incorrect: C. Pulsed Lavage Pulsed lavage is for irrigation and bioburden reduction. * Incorrect: D. Diathermy Diathermy uses heat, not oxygen concentration.
Which therapy utilizes electromagnetic energy to heat tissue and promote wound healing? * A. Diathermy * B. Ultrasound * C. Electrical Stimulation * D. Negative Pressure Wound Therapy
- Correct: A. Diathermy Diathermy uses electromagnetic energy to improve circulation, fibroblast activity, and nitric oxide release. * Incorrect: B. Ultrasound Ultrasound uses sound waves, not electromagnetic energy. * Incorrect: C. Electrical Stimulation Electrical stimulation uses electrical currents, not heat. * Incorrect: D. Negative Pressure Wound Therapy NPWT uses suction, not heat.
Which modality combines irrigation with suction to facilitate debridement and bioburden reduction? * A. Pulsed Lavage * B. Negative Pressure Wound Therapy * C. Whirlpool Therapy * D. Ultrasound
- Correct: A. Pulsed Lavage Pulsed lavage combines pressurized irrigation with suction to reduce bioburden and debride wounds. * Incorrect: B. Negative Pressure Wound Therapy NPWT applies subatmospheric pressure but does not use irrigation. * Incorrect: C. Whirlpool Therapy Whirlpool therapy softens necrotic tissue but does not use suction. * Incorrect: D. Ultrasound Ultrasound uses sound waves, not irrigation and suction.
Which modality uses noncontact low-frequency ultrasound to gently debride wounds? * A. Ultrasound Mist * B. High-Frequency Ultrasound * C. Pulsed Lavage * D. Electrical Stimulation
- Correct: A. Ultrasound Mist Noncontact low-frequency ultrasound (Mist) gently debrides wounds while reducing bioburden. * Incorrect: B. High-Frequency Ultrasound High-frequency ultrasound is used for deeper tissue effects, not noncontact debridement. * Incorrect: C. Pulsed Lavage Pulsed lavage involves irrigation, not ultrasound. * Incorrect: D. Electrical Stimulation Electrical stimulation does not involve ultrasound.
Which therapy is most appropriate for a wound with thick eschar and heavy bioburden? * A. Whirlpool Therapy * B. Negative Pressure Wound Therapy * C. Electrical Stimulation * D. Wound Irrigation
- Correct: A. Whirlpool Therapy Whirlpool therapy softens eschar and reduces bioburden, making it effective for wounds with thick necrotic tissue. * Incorrect: B. Negative Pressure Wound Therapy NPWT requires a clean wound bed and is not suitable for thick eschar. * Incorrect: C. Electrical Stimulation Electrical stimulation does not soften eschar or reduce heavy bioburden. * Incorrect: D. Wound Irrigation While useful, irrigation alone is less effective for thick eschar.
What is a contraindication for using hyperbaric oxygen therapy (HBO)? * A. Claustrophobia * B. Gas gangrene * C. Peripheral ischemia * D. Crush injuries
- Correct: A. Claustrophobia Patients with claustrophobia may struggle with the enclosed environment required for HBO therapy. * Incorrect: B. Gas gangrene HBO is indicated for gas gangrene. * Incorrect: C. Peripheral ischemia HBO is used to treat ischemic wounds. * Incorrect: D. Crush injuries HBO is indicated for crush injuries.
Which modality stimulates mitochondria and growth factor production to enhance wound healing? * A. Low-Intensity Laser Therapy * B. Electrical Stimulation * C. Pulsed Lavage * D. Diathermy
- Correct: A. Low-Intensity Laser Therapy Low-intensity laser therapy stimulates cellular activity, including mitochondrial function and growth factor release. * Incorrect: B. Electrical Stimulation Electrical stimulation attracts cells to the wound site but does not directly stimulate mitochondria. * Incorrect: C. Pulsed Lavage Pulsed lavage does not affect cellular functions like mitochondria or growth factors. * Incorrect: D. Diathermy Diathermy promotes circulation but does not target mitochondria or growth factors.
What is a primary advantage of cold atmospheric plasma (CAP) therapy? * A. Promotes fibroblast proliferation * B. Provides thermal effects * C. Directly softens necrotic tissue * D. Increases oxygen delivery
- Correct: A. Promotes fibroblast proliferation CAP therapy supports fibroblast and keratinocyte proliferation, promoting wound healing. * Incorrect: B. Provides thermal effects CAP therapy is not thermal. * Incorrect: C. Directly softens necrotic tissue CAP does not physically debride tissue. * Incorrect: D. Increases oxygen delivery Oxygen delivery is not a primary effect of CAP.
Which therapy is contraindicated for wounds with exposed organs? * A. Negative Pressure Wound Therapy * B. Whirlpool Therapy * C. Electrical Stimulation * D. Pulsed Lavage
- Correct: A. Negative Pressure Wound Therapy NPWT is contraindicated for wounds with exposed organs unless specialized systems are used. * Incorrect: B. Whirlpool Therapy Whirlpool therapy does not directly harm exposed organs. * Incorrect: C. Electrical Stimulation Electrical stimulation is not directly contraindicated for wounds with exposed organs. * Incorrect: D. Pulsed Lavage Pulsed lavage can be used cautiously but is not contraindicated.
Which modality reduces wound edema while promoting angiogenesis and granulation tissue formation? * A. Negative Pressure Wound Therapy * B. Hyperbaric Oxygen Therapy * C. Ultrasound * D. Electrical Stimulation
- Correct: A. Negative Pressure Wound Therapy NPWT decreases edema and promotes granulation and angiogenesis. * Incorrect: B. Hyperbaric Oxygen Therapy HBO promotes angiogenesis but does not reduce edema. * Incorrect: C. Ultrasound Ultrasound facilitates healing but does not directly reduce edema. * Incorrect: D. Electrical Stimulation Electrical stimulation improves circulation but is less effective for edema reduction.
Which therapy is particularly useful for reducing bioburden in critically colonized category III/IV pressure ulcers? * A. Ultraviolet C Therapy * B. Electrical Stimulation * C. Low-Intensity Laser Therapy * D. Whirlpool Therapy
- Correct: A. Ultraviolet C Therapy UVC therapy is bactericidal and helps reduce bioburden in critically colonized pressure ulcers. * Incorrect: B. Electrical Stimulation Electrical stimulation promotes healing but does not directly reduce bioburden. * Incorrect: C. Low-Intensity Laser Therapy Laser therapy has limited evidence for bioburden reduction. * Incorrect: D. Whirlpool Therapy Whirlpool therapy is not as specific for bioburden in pressure ulcers.
What is the primary goal of using a support surface in pressure relief? * A. To reduce edema in the lower extremities * B. To redistribute body weight and protect skin tissue * C. To prevent heat loss in patients * D. To assist with pulmonary therapy
- Correct: B. To redistribute body weight and protect skin tissue Support surfaces are designed to redistribute pressure and protect vulnerable areas, like bony prominences, from breakdown. * Incorrect: A. To reduce edema in the lower extremities Edema reduction is not the main goal of support surfaces. * Incorrect: C. To prevent heat loss in patients Preventing heat loss is unrelated to pressure relief. * Incorrect: D. To assist with pulmonary therapy Pulmonary therapy may involve different types of support but is not the primary goal here.
What tissue interface pressure is considered the threshold for skin breakdown? * A. 15 mmHg * B. 23 mmHg * C. 32 mmHg * D. 45 mmHg
- Correct: C. 32 mmHg Tissue interface pressures above 32 mmHg are associated with impaired capillary blood flow, leading to tissue breakdown. * Incorrect: A. 15 mmHg This pressure is too low to cause significant breakdown. * Incorrect: B. 23 mmHg This is the range for pressure-relieving devices, not the breakdown threshold. * Incorrect: D. 45 mmHg This is above the threshold but not a commonly cited value for breakdown risk.
What is the purpose of pressure mapping in pressure relief management? * A. To diagnose existing pressure ulcers * B. To map patient mobility patterns * C. To assess how interface pressure affects tissue loading * D. To design custom support surfaces
- Correct: C. To assess how interface pressure affects tissue loading Pressure mapping evaluates tissue loading by measuring interface pressure between the patient and the surface. * Incorrect: A. To diagnose existing pressure ulcers Diagnosis of ulcers is based on clinical assessment, not pressure mapping. * Incorrect: B. To map patient mobility patterns Pressure mapping focuses on static pressure, not mobility. * Incorrect: D. To design custom support surfaces While it provides data, it is not directly used to design surfaces.
Which type of support surface provides continuous air circulation to manage heat and moisture? * A. Low Air Loss * B. Alternating Pressure * C. Air-Fluidized Beds * D. Viscoelastic Foam
- Correct: A. Low Air Loss Low air loss mattresses continuously circulate air to manage heat and moisture at the patient-surface interface. * Incorrect: B. Alternating Pressure Alternating pressure redistributes pressure through cyclic inflation, not air circulation. * Incorrect: C. Air-Fluidized Beds These beds use air to create a fluid-like medium but do not focus on moisture control. * Incorrect: D. Viscoelastic Foam Foam does not provide active air circulation.
What is a major disadvantage of lateral rotation beds in pressure management? * A. They are uncomfortable for most patients * B. They increase the risk of shear injuries * C. They are ineffective for pulmonary therapy * D. They are too costly for most healthcare settings
- Correct: B. They increase the risk of shear injuries Lateral rotation beds can cause excessive shear forces, increasing the risk of tissue injury. * Incorrect: A. They are uncomfortable for most patients Discomfort is not commonly cited as a major disadvantage. * Incorrect: C. They are ineffective for pulmonary therapy These beds are often used for pulmonary therapy. * Incorrect: D. They are too costly for most healthcare settings While they are costly, this is not their primary disadvantage in pressure management.
Which type of support surface is most appropriate for a patient with a stage III or IV pressure ulcer who is bedridden? * A. Standard Foam Mattress * B. Low Air Loss Mattress * C. Air-Fluidized Bed * D. Alternating Pressure Mattress
- Correct: C. Air-Fluidized Bed Air-fluidized beds provide advanced pressure relief and are indicated for stage III or IV pressure ulcers. * Incorrect: A. Standard Foam Mattress These mattresses do not provide sufficient pressure relief for advanced ulcers. * Incorrect: B. Low Air Loss Mattress While effective, these are typically used for less severe cases. * Incorrect: D. Alternating Pressure Mattress Alternating pressure mattresses are appropriate but less effective than air-fluidized beds for advanced cases.
Which support surface technology minimizes shear forces while maintaining immersion and envelopment? * A. Air-Fluidized Beds * B. Alternating Pressure Mattresses * C. Low Air Loss Mattresses * D. Foam Mattresses
- Correct: A. Air-Fluidized Beds These beds reduce shear while providing excellent immersion and envelopment. * Incorrect: B. Alternating Pressure Mattresses These redistribute pressure but do not significantly minimize shear forces. * Incorrect: C. Low Air Loss Mattresses Low air loss mattresses focus on heat and moisture control rather than shear reduction. * Incorrect: D. Foam Mattresses Foam mattresses may reduce pressure but are less effective at shear reduction.
Which type of positioning is recommended to minimize pressure on the sacrum and coccyx? * A. Semi-Recumbent * B. 30-Degree Tilted Side-Lying * C. 90-Degree Side-Lying * D. Supine
- Correct: B. 30-Degree Tilted Side-Lying This position offloads pressure from the sacrum and coccyx, reducing risk of pressure injury. * Incorrect: A. Semi-Recumbent This position increases pressure on the sacrum and coccyx. * Incorrect: C. 90-Degree Side-Lying This position increases pressure on the greater trochanter. * Incorrect: D. Supine Supine positioning places direct pressure on the sacrum and coccyx.
How often should patients who are immobile be repositioned to prevent pressure ulcers? * A. Every 30 minutes * B. Every 1–2 hours * C. Every 4 hours * D. Every 6 hours
- Correct: B. Every 1–2 hours Immobile patients should be repositioned every 1–2 hours to prevent pressure ulcers. * Incorrect: A. Every 30 minutes While more frequent repositioning is beneficial, it is not standard practice. * Incorrect: C. Every 4 hours This frequency may increase the risk of pressure injuries. * Incorrect: D. Every 6 hours This is too infrequent to effectively prevent ulcers.
What is the purpose of a viscoelastic foam mattress? * A. To prevent heat loss * B. To redistribute pressure and conform to body contours * C. To reduce shear forces * D. To enhance moisture evaporation
- Correct: B. To redistribute pressure and conform to body contours Viscoelastic foam molds to the body, redistributing pressure. * Incorrect: A. To prevent heat loss Foam mattresses are not designed for heat management. * Incorrect: C. To reduce shear forces Foam does not significantly reduce shear forces. * Incorrect: D. To enhance moisture evaporation Foam does not actively manage moisture.
Which type of mattress is most appropriate for patients with multiple stage II pressure ulcers that have not improved with standard care? * A. Air-Fluidized Mattress * B. Low Air Loss Mattress * C. Alternating Pressure Mattress * D. Viscoelastic Foam Mattress
- Correct: B. Low Air Loss Mattress Low air loss mattresses are indicated for patients with stage II ulcers that have not improved with standard care. * Incorrect: A. Air-Fluidized Mattress These are typically reserved for advanced stage III or IV ulcers. * Incorrect: C. Alternating Pressure Mattress Alternating pressure mattresses are often a step before low air loss mattresses. * Incorrect: D. Viscoelastic Foam Mattress Foam mattresses are for prevention and less severe cases.
What is the primary advantage of using an alternating pressure mattress? * A. Continuous air circulation * B. Cyclic redistribution of pressure * C. Reduced moisture at the wound site * D. Enhanced immersion and envelopment
- Correct: B. Cyclic redistribution of pressure Alternating pressure mattresses cyclically inflate and deflate to redistribute pressure across different body areas. * Incorrect: A. Continuous air circulation This is a feature of low air loss mattresses, not alternating pressure systems. * Incorrect: C. Reduced moisture at the wound site Moisture management is not the primary function of alternating pressure. * Incorrect: D. Enhanced immersion and envelopment This is more typical of air-fluidized beds.
Which positioning technique reduces pressure on the ischial tuberosities in a wheelchair? * A. Reclining backward * B. Side-lean * C. Forward lean * D. Push-up pressure relief
- Correct: C. Forward lean Leaning forward effectively offloads the ischial tuberosities. * Incorrect: A. Reclining backward Reclining may redistribute pressure but does not specifically offload the ischial tuberosities. * Incorrect: B. Side-lean Side-lean redistributes pressure to one side but not from the ischial tuberosities. * Incorrect: D. Push-up pressure relief This offloads the buttocks entirely, not specifically the ischial tuberosities.
What is the purpose of the 30-degree tilted side-lying position? * A. To offload the greater trochanter * B. To reduce moisture accumulation * C. To minimize shear forces * D. To facilitate pulmonary drainage
- Correct: A. To offload the greater trochanter The 30-degree tilted side-lying position reduces pressure on the greater trochanter. * Incorrect: B. To reduce moisture accumulation This position does not directly address moisture control. * Incorrect: C. To minimize shear forces Shear reduction is not the primary goal of this position. * Incorrect: D. To facilitate pulmonary drainage Pulmonary drainage is not the intended outcome.
What type of support surface uses air-filled bladders to redistribute pressure evenly? * A. Low Air Loss Mattress * B. Fluid-Filled Bladders * C. Air-Fluidized Mattress * D. Alternating Pressure Mattress
- Correct: B. Fluid-Filled Bladders Fluid-filled bladders evenly distribute pressure across the surface area. * Incorrect: A. Low Air Loss Mattress These manage heat and moisture but do not use fluid-filled bladders. * Incorrect: C. Air-Fluidized Mattress These create a fluid-like medium using air, not fluid bladders. * Incorrect: D. Alternating Pressure Mattress These rely on cyclic inflation and deflation, not fluid-filled components.
Which type of support surface is contraindicated for patients with active bleeding? * A. Air-Fluidized Mattress * B. Alternating Pressure Mattress * C. Low Air Loss Mattress * D. Foam Mattress
- Correct: A. Air-Fluidized Mattress Air-fluidized beds are contraindicated for patients with active bleeding due to their effect on moisture evaporation and potential for bleeding exacerbation. * Incorrect: B. Alternating Pressure Mattress These are not contraindicated for active bleeding. * Incorrect: C. Low Air Loss Mattress Low air loss mattresses are suitable for patients with active bleeding. * Incorrect: D. Foam Mattress Foam mattresses are not contraindicated.
How often should wheelchair-bound patients perform pressure relief techniques? * A. Every 15–30 minutes * B. Every 1–2 hours * C. Every 4 hours * D. Every 6 hours
- Correct: A. Every 15–30 minutes Wheelchair users should perform pressure relief techniques every 15–30 minutes to prevent pressure injuries. * Incorrect: B. Every 1–2 hours This frequency is recommended for bed-bound patients, not wheelchair users. * Incorrect: C. Every 4 hours This is too infrequent to prevent pressure injuries. * Incorrect: D. Every 6 hours This is insufficient to prevent pressure injuries.
Which type of ulcer requires elevation and offloading of the heels to prevent further damage? * A. Trochanteric ulcer * B. Sacral ulcer * C. Heel ulcer * D. Coccygeal ulcer
- Correct: C. Heel ulcer Elevating and offloading the heels is critical for managing and preventing further damage to heel ulcers. * Incorrect: A. Trochanteric ulcer Trochanteric ulcers require offloading from the greater trochanter, not the heels. * Incorrect: B. Sacral ulcer Sacral ulcers require offloading from the sacrum. * Incorrect: D. Coccygeal ulcer Coccygeal ulcers also require offloading but not from the heels.
What is a disadvantage of gel overlays used in support surfaces? * A. They are costly to manufacture * B. They retain body heat and can warm over time * C. They lack pressure redistribution capabilities * D. They are ineffective for multiple pressure ulcers
- Correct: B. They retain body heat and can warm over time Gel overlays absorb body heat, initially feeling cool but warming over time, which can cause discomfort. * Incorrect: A. They are costly to manufacture Cost is not a primary disadvantage. * Incorrect: C. They lack pressure redistribution capabilities Gel overlays do provide pressure redistribution. * Incorrect: D. They are ineffective for multiple pressure ulcers Gel overlays can be effective for multiple ulcers.
What is a key feature of lateral rotation beds that makes them beneficial for pulmonary therapy? * A. Pressure redistribution * B. Cyclic inflation and deflation * C. Positioning one lung higher than the other * D. Managing heat and moisture
- Correct: C. Positioning one lung higher than the other Lateral rotation beds assist in pulmonary therapy by positioning one lung higher to prevent pneumonia. * Incorrect: A. Pressure redistribution While they redistribute pressure, this is not specific to pulmonary therapy. * Incorrect: B. Cyclic inflation and deflation This is a feature of alternating pressure beds, not lateral rotation beds. * Incorrect: D. Managing heat and moisture This is not the primary function of lateral rotation beds.
What is the primary function of the tunica media in arteries? * A. Protect vessel walls from trauma * B. Regulate vessel diameter * C. Facilitate oxygen exchange * D. Provide structural support
- Correct: B. Regulate vessel diameter The tunica media, composed of smooth muscle, modulates vessel diameter to regulate blood flow. * Incorrect: A. Protect vessel walls from trauma This is the function of the tunica externa. * Incorrect: C. Facilitate oxygen exchange Oxygen exchange occurs at the capillaries. * Incorrect: D. Provide structural support Structural support is the role of the tunica externa.
Which condition is the most common cause of arterial ulcers? * A. Diabetes mellitus * B. Arteriosclerosis * C. Thromboangiitis obliterans * D. Trauma
- Correct: B. Arteriosclerosis Arteriosclerosis leads to thickening and hardening of the arterial walls, decreasing perfusion and causing ulcers. * Incorrect: A. Diabetes mellitus Diabetes contributes to arterial insufficiency but is not the most common direct cause. * Incorrect: C. Thromboangiitis obliterans This is a rare condition associated with arterial ulcers. * Incorrect: D. Trauma Trauma may precipitate arterial ulcers but is not the primary cause.
What is intermittent claudication? * A. Pain at rest caused by ischemia * B. Activity-induced discomfort relieved by rest * C. Burning pain exacerbated by elevation * D. Pain caused by venous insufficiency
- Correct: B. Activity-induced discomfort relieved by rest Intermittent claudication is ischemic pain triggered by activity and relieved within minutes of rest. * Incorrect: A. Pain at rest caused by ischemia This describes ischemic rest pain, not claudication. * Incorrect: C. Burning pain exacerbated by elevation This also describes ischemic rest pain. * Incorrect: D. Pain caused by venous insufficiency Claudication is specific to arterial insufficiency, not venous issues.
Where are arterial ulcers most commonly located? * A. Medial malleolus * B. Anterior leg and lateral malleolus * C. Popliteal fossa * D. Thigh
- Correct: B. Anterior leg and lateral malleolus Arterial ulcers are typically found in the lower extremities, particularly the anterior leg and lateral malleolus. * Incorrect: A. Medial malleolus This is a common location for venous ulcers. * Incorrect: C. Popliteal fossa Arterial ulcers are rarely found in this area. * Incorrect: D. Thigh Arterial ulcers are uncommon in the thigh.
Which symptom is most indicative of arterial insufficiency? * A. Swelling and edema * B. Dependent rubor and elevational pallor * C. Varicose veins * D. Warm skin temperature
- Correct: B. Dependent rubor and elevational pallor These signs indicate impaired arterial perfusion and are hallmark symptoms of arterial insufficiency. * Incorrect: A. Swelling and edema These are more indicative of venous insufficiency. * Incorrect: C. Varicose veins These are associated with venous insufficiency. * Incorrect: D. Warm skin temperature Cool skin temperature is a characteristic of arterial insufficiency.
What are the characteristic features of arterial ulcers? * A. Irregular, shallow wounds with heavy exudate * B. Well-defined, dry, and “punched out” wounds * C. Circular, moist wounds with granulation tissue * D. Large, weeping wounds above the knee
- Correct: B. Well-defined, dry, and “punched out” wounds Arterial ulcers often have smooth edges and are associated with dry necrosis. * Incorrect: A. Irregular, shallow wounds with heavy exudate These are features of venous ulcers. * Incorrect: C. Circular, moist wounds with granulation tissue Moist wounds are more indicative of pressure or mixed ulcers. * Incorrect: D. Large, weeping wounds above the knee Arterial ulcers are usually located below the knee.
What is the primary purpose of measuring the Ankle-Brachial Index (ABI)? * A. Assess oxygenation of tissues * B. Diagnose venous insufficiency * C. Determine the severity of arterial insufficiency * D. Identify neuropathic involvement
- Correct: C. Determine the severity of arterial insufficiency ABI compares upper and lower extremity pressures to evaluate arterial perfusion. * Incorrect: A. Assess oxygenation of tissues Oxygenation is measured with tcpO2, not ABI. * Incorrect: B. Diagnose venous insufficiency ABI assesses arterial insufficiency, not venous issues. * Incorrect: D. Identify neuropathic involvement ABI is unrelated to neuropathic assessment.
Which dressing is most appropriate for an arterial ulcer with dry necrotic tissue and adequate perfusion? * A. Hydrogel with a secondary dressing * B. Foam dressing * C. Alginate * D. Hydrocolloid
- Correct: A. Hydrogel with a secondary dressing Hydrogel provides moisture to the wound bed, softening necrotic tissue for autolytic debridement. * Incorrect: B. Foam dressing Foam dressings are not typically used for dry necrotic wounds. * Incorrect: C. Alginate Alginate is better suited for wounds with heavy exudate. * Incorrect: D. Hydrocolloid Hydrocolloids are not ideal for arterial ulcers with dry necrosis.
What is a contraindication for debridement of arterial ulcers? * A. Presence of slough * B. ABI <0.5 * C. Toe pressure >50 mmHg * D. Moderate exudate
- Correct: B. ABI <0.5 Debridement is contraindicated when perfusion is insufficient to support healing (ABI <0.5). * Incorrect: A. Presence of slough Slough may require debridement if perfusion is adequate. * Incorrect: C. Toe pressure >50 mmHg This indicates sufficient perfusion for debridement. * Incorrect: D. Moderate exudate Exudate level does not contraindicate debridement.
What is the recommended intervention goal for arterial ulcers with impaired perfusion? * A. Apply compression therapy * B. Maintain warmth and avoid compression * C. Aggressively debride necrotic tissue * D. Use foam dressings for heavy exudate
- Correct: B. Maintain warmth and avoid compression Maintaining warmth supports circulation, while compression is contraindicated for impaired perfusion. * Incorrect: A. Apply compression therapy Compression is contraindicated in arterial insufficiency. * Incorrect: C. Aggressively debride necrotic tissue Debridement is contraindicated with impaired perfusion. * Incorrect: D. Use foam dressings for heavy exudate Foam dressings are not ideal for dry wounds.
Which risk factor is most strongly associated with the progression of arterial insufficiency ulcers? * A. Smoking * B. Advanced age * C. Trauma * D. Hypertension
- Correct: A. Smoking Smoking significantly contributes to arterial insufficiency by causing vasoconstriction, increasing clot formation, and reducing oxygen availability. * Incorrect: B. Advanced age While age is a risk factor, smoking has a stronger association with progression. * Incorrect: C. Trauma Trauma is often a precipitating factor but not the primary contributor to progression. * Incorrect: D. Hypertension Hypertension contributes but less significantly than smoking.
What is the purpose of the Rubor of Dependency test? * A. Assess venous reflux * B. Evaluate arterial flow in the lower extremities * C. Determine capillary refill time * D. Measure oxygenation in tissues
- Correct: B. Evaluate arterial flow in the lower extremities The Rubor of Dependency test evaluates arterial blood flow by observing color changes with leg elevation and dependency. * Incorrect: A. Assess venous reflux This test does not evaluate venous function. * Incorrect: C. Determine capillary refill time Capillary refill is assessed separately using nail bed pressure. * Incorrect: D. Measure oxygenation in tissues Tissue oxygenation is measured with tcpO2, not this test.
Which finding indicates severe arterial insufficiency on an Ankle-Brachial Index (ABI) test? * A. ABI ≥ 1.3 * B. ABI 0.95–1.0 * C. ABI 0.5–0.8 * D. ABI <0.5
- Correct: D. ABI <0.5 An ABI value below 0.5 indicates severe arterial insufficiency, often associated with rest pain or tissue loss. * Incorrect: A. ABI ≥ 1.3 This suggests calcified, non-compressible vessels, common in diabetes or CKD. * Incorrect: B. ABI 0.95–1.0 This range is considered normal. * Incorrect: C. ABI 0.5–0.8 This range indicates moderate arterial disease.
What adjunctive modality is most appropriate for arterial ulcers with adequate perfusion? * A. Negative Pressure Wound Therapy * B. Hyperbaric Oxygen Therapy * C. Low-Intensity Laser Therapy * D. Electrical Stimulation
- Correct: B. Hyperbaric Oxygen Therapy HBO improves oxygenation and promotes healing in well-perfused arterial ulcers. * Incorrect: A. Negative Pressure Wound Therapy NPWT is contraindicated for poorly perfused wounds. * Incorrect: C. Low-Intensity Laser Therapy While helpful, HBO is more directly beneficial for arterial ulcers. * Incorrect: D. Electrical Stimulation Electrical stimulation is useful but secondary to HBO in arterial ulcers.
What is the clinical significance of dependent rubor in arterial insufficiency? * A. Indicates venous congestion * B. Suggests collateral circulation is intact * C. Demonstrates arterial insufficiency with reactive hyperemia * D. Confirms the presence of neuropathy
- Correct: C. Demonstrates arterial insufficiency with reactive hyperemia Dependent rubor is a classic sign of arterial insufficiency and indicates poor perfusion. * Incorrect: A. Indicates venous congestion Venous congestion does not cause dependent rubor. * Incorrect: B. Suggests collateral circulation is intact Dependent rubor suggests inadequate arterial perfusion, not sufficient collateral circulation. * Incorrect: D. Confirms the presence of neuropathy Neuropathy does not typically cause dependent rubor.
What is the primary indication for transcutaneous oxygen pressure (tcpO2) testing in arterial ulcers? * A. To assess venous insufficiency * B. To evaluate oxygen diffusion across the skin * C. To measure ankle pressure * D. To determine the risk of neuropathy
- Correct: B. To evaluate oxygen diffusion across the skin TcpO2 measures oxygen diffusion to assess tissue perfusion. * Incorrect: A. To assess venous insufficiency TcpO2 is used for arterial, not venous, evaluation. * Incorrect: C. To measure ankle pressure Ankle pressures are measured using ABI, not tcpO2. * Incorrect: D. To determine the risk of neuropathy TcpO2 does not assess neuropathy risk.
What is the recommended treatment goal for arterial ulcers with ischemic rest pain? * A. Aggressive debridement * B. Revascularization * C. Compression therapy * D. Autolytic debridement
- Correct: B. Revascularization Revascularization is essential to restore blood flow and relieve ischemic rest pain. * Incorrect: A. Aggressive debridement Debridement is contraindicated without adequate perfusion. * Incorrect: C. Compression therapy Compression is contraindicated in arterial insufficiency. * Incorrect: D. Autolytic debridement Autolytic debridement is not effective without adequate perfusion.
Which dressing is contraindicated for arterial ulcers with dry necrosis and inadequate perfusion? * A. Hydrocolloid * B. Non-adherent foam * C. Hydrogel * D. Alginate
- Correct: A. Hydrocolloid Hydrocolloids are occlusive and not recommended for dry necrotic arterial ulcers. * Incorrect: B. Non-adherent foam Foam dressings are suitable for protecting dry necrotic areas. * Incorrect: C. Hydrogel Hydrogel is appropriate for moistening dry necrotic tissue. * Incorrect: D. Alginate Alginate is inappropriate for dry wounds but is not contraindicated.
Which factor contributes most significantly to arterial ulcer progression? * A. Hyperlipidemia * B. Impaired wound healing * C. Smoking * D. Poor glycemic control
- Correct: C. Smoking Smoking exacerbates arterial insufficiency by increasing clot formation, vasoconstriction, and reducing oxygen delivery. * Incorrect: A. Hyperlipidemia While significant, hyperlipidemia contributes less directly than smoking. * Incorrect: B. Impaired wound healing Impaired healing is a consequence, not a primary contributor. * Incorrect: D. Poor glycemic control Glycemic control impacts arterial health but less than smoking.
What is the best initial step in managing arterial ulcers with ABI <0.5? * A. Compression therapy * B. Surgical debridement * C. Revascularization consultation * D. Apply hydrogel dressing
- Correct: C. Revascularization consultation Immediate revascularization is required for severe arterial insufficiency. * Incorrect: A. Compression therapy Compression is contraindicated with ABI <0.5. * Incorrect: B. Surgical debridement Debridement is unsafe without adequate perfusion. * Incorrect: D. Apply hydrogel dressing Hydrogel does not address perfusion issues.
What is the primary cause of neuropathic ulcers in patients with diabetes? * A. Venous insufficiency * B. Peripheral neuropathy * C. Arterial insufficiency * D. Pressure injuries
- Correct: B. Peripheral neuropathy Peripheral neuropathy leads to loss of sensation, making patients unaware of injuries and pressure, which can lead to ulceration. * Incorrect: A. Venous insufficiency Venous insufficiency causes different types of ulcers. * Incorrect: C. Arterial insufficiency Arterial insufficiency is not the primary cause of neuropathic ulcers. * Incorrect: D. Pressure injuries Pressure injuries can contribute but are secondary to neuropathy.
Which factor contributes most significantly to delayed wound healing in patients with diabetes? * A. Poor glycemic control * B. Advanced age * C. Inadequate protein intake * D. Lack of exercise
- Correct: A. Poor glycemic control Hyperglycemia impairs immune function, collagen synthesis, and angiogenesis, delaying wound healing. * Incorrect: B. Advanced age While age is a factor, poor glycemic control is more significant in diabetes. * Incorrect: C. Inadequate protein intake Protein deficiency affects healing but is not the primary issue in diabetes. * Incorrect: D. Lack of exercise Exercise affects overall health but is less directly linked to delayed wound healing.
What is the hallmark characteristic of a neuropathic ulcer? * A. Irregular edges with heavy exudate * B. Well-defined margins with surrounding callus * C. Painful wound with erythematous base * D. Punched-out appearance with dry necrosis
- Correct: B. Well-defined margins with surrounding callus Neuropathic ulcers typically have well-defined margins and callus around the wound due to repetitive trauma and pressure. * Incorrect: A. Irregular edges with heavy exudate These are characteristics of venous ulcers. * Incorrect: C. Painful wound with erythematous base Neuropathic ulcers are often painless due to sensory loss. * Incorrect: D. Punched-out appearance with dry necrosis This describes arterial ulcers.
Where are neuropathic ulcers most commonly located? * A. Dorsum of the foot * B. Medial malleolus * C. Plantar aspect of the foot * D. Popliteal fossa
- Correct: C. Plantar aspect of the foot Neuropathic ulcers commonly occur on weight-bearing areas like the plantar surface. * Incorrect: A. Dorsum of the foot This location is less typical for neuropathic ulcers. * Incorrect: B. Medial malleolus This is a common site for venous ulcers. * Incorrect: D. Popliteal fossa Neuropathic ulcers do not typically occur in this area.
What is the purpose of a 10-gram monofilament test? * A. Assess motor neuropathy * B. Evaluate arterial blood flow * C. Identify loss of protective sensation * D. Determine autonomic dysfunction
- Correct: C. Identify loss of protective sensation The monofilament test assesses sensory function to identify areas of diminished sensation. * Incorrect: A. Assess motor neuropathy Motor neuropathy involves muscle weakness, not sensory loss. * Incorrect: B. Evaluate arterial blood flow The monofilament test does not assess circulation. * Incorrect: D. Determine autonomic dysfunction The test does not evaluate autonomic functions.
What is the gold standard off-loading device for neuropathic ulcers? * A. Total contact cast * B. Diabetic shoes * C. Gel heel cushion * D. Knee scooter
- Correct: A. Total contact cast Total contact casting evenly redistributes pressure, protecting the ulcer and promoting healing. * Incorrect: B. Diabetic shoes Diabetic shoes are effective for prevention but not the gold standard for treatment. * Incorrect: C. Gel heel cushion Heel cushions reduce pressure locally but are not comprehensive solutions. * Incorrect: D. Knee scooter Knee scooters are used for mobility, not pressure off-loading.
Which type of neuropathy is responsible for autonomic dysfunction in diabetic patients? * A. Sensory neuropathy * B. Motor neuropathy * C. Autonomic neuropathy * D. Mixed neuropathy
- Correct: C. Autonomic neuropathy Autonomic neuropathy affects involuntary functions, such as sweat production and blood flow, contributing to diabetic wound pathology. * Incorrect: A. Sensory neuropathy Sensory neuropathy involves loss of protective sensation, not autonomic function. * Incorrect: B. Motor neuropathy Motor neuropathy causes muscle weakness, not autonomic dysfunction. * Incorrect: D. Mixed neuropathy While mixed neuropathy may involve autonomic dysfunction, the specific cause here is autonomic neuropathy.
What is the significance of elevated plantar pressure in diabetic patients? * A. Increased risk of arterial insufficiency ulcers * B. Decreased callus formation * C. Increased risk of neuropathic ulcers * D. Improved blood flow to the toes
- Correct: C. Increased risk of neuropathic ulcers Elevated plantar pressure exacerbates tissue damage, leading to ulcer formation in patients with sensory loss. * Incorrect: A. Increased risk of arterial insufficiency ulcers Arterial ulcers are not caused by plantar pressure. * Incorrect: B. Decreased callus formation Plantar pressure increases callus formation. * Incorrect: D. Improved blood flow to the toes Elevated pressure does not improve circulation.
What is a contraindication for total contact casting? * A. Plantar ulcers with moderate exudate * B. Presence of infection or osteomyelitis * C. Neuropathic ulcers in non-weight-bearing areas * D. Patients with normal sensation
- Correct: B. Presence of infection or osteomyelitis Total contact casting is contraindicated when infection or osteomyelitis is present, as it can exacerbate the condition. * Incorrect: A. Plantar ulcers with moderate exudate Total contact casting can still be used for exudative ulcers with appropriate dressings. * Incorrect: C. Neuropathic ulcers in non-weight-bearing areas Off-loading is not required for non-weight-bearing areas. * Incorrect: D. Patients with normal sensation Total contact casting is primarily for those with sensory loss.
What is the recommended frequency for diabetic foot inspections to prevent ulcer development? * A. Weekly * B. Biweekly * C. Daily * D. Monthly
- Correct: C. Daily Diabetic patients should inspect their feet daily to identify early signs of injury or ulceration. * Incorrect: A. Weekly Weekly inspections may miss early signs of injury. * Incorrect: B. Biweekly This frequency is insufficient for high-risk patients. * Incorrect: D. Monthly Monthly inspections are not frequent enough for prevention.
What is the role of autonomic neuropathy in the development of diabetic foot ulcers? * A. Increases tissue oxygenation * B. Reduces sweat production, causing dry and cracked skin * C. Enhances vascular dilation * D. Strengthens plantar muscles
- Correct: B. Reduces sweat production, causing dry and cracked skin Autonomic neuropathy reduces sweat production, leading to dry skin and fissures that increase ulcer risk. * Incorrect: A. Increases tissue oxygenation Autonomic dysfunction reduces perfusion rather than improving oxygenation. * Incorrect: C. Enhances vascular dilation It impairs vascular regulation, not dilation. * Incorrect: D. Strengthens plantar muscles Motor neuropathy affects muscles, not autonomic neuropathy.
What is the first step in managing a diabetic foot ulcer with signs of infection? * A. Apply an alginate dressing * B. Start broad-spectrum antibiotics * C. Perform surgical debridement * D. Initiate total contact casting
- Correct: B. Start broad-spectrum antibiotics Antibiotics address infection, which must be managed before other interventions like debridement or casting. * Incorrect: A. Apply an alginate dressing Dressings alone do not manage infections. * Incorrect: C. Perform surgical debridement Debridement can spread infection if not controlled first. * Incorrect: D. Initiate total contact casting Casting is contraindicated in the presence of infection.
Which test is most commonly used to evaluate protective sensation in diabetic patients? * A. Tuning fork test * B. 10-gram monofilament test * C. Ankle-brachial index (ABI) * D. Transcutaneous oxygen pressure (tcpO2)
- Correct: B. 10-gram monofilament test The monofilament test is the gold standard for identifying loss of protective sensation. * Incorrect: A. Tuning fork test The tuning fork evaluates vibratory sensation, not protective sensation. * Incorrect: C. Ankle-brachial index (ABI) ABI assesses arterial perfusion, not sensation. * Incorrect: D. Transcutaneous oxygen pressure (tcpO2) TcpO2 measures tissue oxygenation, not sensory function.
What is a primary characteristic of motor neuropathy in diabetic patients? * A. Loss of sensation * B. Muscle atrophy and foot deformities * C. Increased sweat production * D. Elevated plantar pressures
- Correct: B. Muscle atrophy and foot deformities Motor neuropathy causes intrinsic muscle weakness, leading to deformities like claw toes. * Incorrect: A. Loss of sensation This is a feature of sensory neuropathy, not motor neuropathy. * Incorrect: C. Increased sweat production Autonomic neuropathy reduces, not increases, sweat production. * Incorrect: D. Elevated plantar pressures This results from foot deformities caused by motor neuropathy but is not a direct characteristic.
What is the purpose of a Charcot restraint orthotic walker (CROW)? * A. Enhance vascular flow to the foot * B. Off-load pressure and immobilize the foot * C. Improve ankle joint mobility * D. Reduce sweat production in autonomic neuropathy
- Correct: B. Off-load pressure and immobilize the foot The CROW device redistributes pressure and immobilizes the foot to facilitate healing. * Incorrect: A. Enhance vascular flow to the foot It does not improve vascular flow. * Incorrect: C. Improve ankle joint mobility The CROW is designed for immobilization, not mobility. * Incorrect: D. Reduce sweat production in autonomic neuropathy It does not address autonomic dysfunction.
Which intervention is most effective in preventing recurrence of neuropathic ulcers? * A. Total contact casting * B. Daily foot inspections and protective footwear * C. Routine whirlpool therapy * D. Application of hydrogel dressings
- Correct: B. Daily foot inspections and protective footwear Regular inspections and appropriate footwear prevent injury and reduce recurrence risk. * Incorrect: A. Total contact casting Casting is effective for treatment but not prevention. * Incorrect: C. Routine whirlpool therapy Whirlpool therapy is not indicated for prevention. * Incorrect: D. Application of hydrogel dressings Dressings are for wound management, not prevention.
What is the best strategy to reduce plantar pressures in diabetic patients? * A. Custom-molded orthotics * B. Heel cushions * C. Increased walking activity * D. Surgical intervention
- Correct: A. Custom-molded orthotics Orthotics redistribute plantar pressure, reducing the risk of ulceration. * Incorrect: B. Heel cushions Cushions only address localized pressure and are not sufficient alone. * Incorrect: C. Increased walking activity Excessive activity may increase plantar pressures and injury risk. * Incorrect: D. Surgical intervention Surgery is reserved for severe cases or deformities.
Which sign is most indicative of infection in a diabetic foot ulcer? * A. Presence of granulation tissue * B. Increased exudate and erythema * C. Dry wound bed * D. Reduced wound size
- Correct: B. Increased exudate and erythema These signs indicate inflammation and possible infection in a diabetic ulcer. * Incorrect: A. Presence of granulation tissue Granulation tissue is a sign of healing, not infection. * Incorrect: C. Dry wound bed A dry wound bed does not necessarily indicate infection. * Incorrect: D. Reduced wound size Reduction in size is a sign of healing.
Which off-loading device is appropriate for a patient who cannot tolerate total contact casting? * A. Charcot restraint orthotic walker (CROW) * B. Diabetic shoes with custom inserts * C. Gel heel cushion * D. Ankle-foot orthosis (AFO)
- Correct: A. Charcot restraint orthotic walker (CROW) The CROW is an alternative off-loading device for patients unable to tolerate casting. * Incorrect: B. Diabetic shoes with custom inserts These are preventive measures, not substitutes for casting. * Incorrect: C. Gel heel cushion Cushions provide localized relief but are insufficient for significant off-loading. * Incorrect: D. Ankle-foot orthosis (AFO) AFOs are used for support but do not redistribute pressure.
What is the ideal ABI range for safe compression therapy in diabetic patients? * A. 0.9–1.2 * B. 0.8–1.0 * C. 0.5–0.7 * D. <0.5
- Correct: B. 0.8–1.0 ABI values in this range indicate sufficient arterial perfusion for safe compression. * Incorrect: A. 0.9–1.2 While normal, this range may not include all diabetic patients. * Incorrect: C. 0.5–0.7 This range indicates moderate arterial insufficiency, making compression risky. * Incorrect: D. <0.5 ABI below 0.5 is contraindicated for compression therapy.
What is the primary function of venous valves? * A. Propel blood forward using muscle contraction * B. Prevent backflow of blood * C. Facilitate oxygen exchange * D. Regulate venous blood pressure
- Correct: B. Prevent backflow of blood Venous valves ensure unidirectional flow of blood toward the heart. * Incorrect: A. Propel blood forward using muscle contraction Propulsion is achieved by the muscle pump, not valves. * Incorrect: C. Facilitate oxygen exchange Oxygen exchange occurs in capillaries, not veins. * Incorrect: D. Regulate venous blood pressure Pressure regulation involves multiple factors, not solely valves.
Which of the following is a primary risk factor for venous insufficiency? * A. Prolonged standing * B. Low blood pressure * C. Sedentary lifestyle * D. Low BMI
- Correct: A. Prolonged standing Standing for extended periods increases venous pressure and contributes to valve dysfunction. * Incorrect: B. Low blood pressure Low blood pressure does not cause venous insufficiency. * Incorrect: C. Sedentary lifestyle While relevant, it is less directly linked than prolonged standing. * Incorrect: D. Low BMI High BMI is a more significant risk factor.
What is the hallmark clinical sign of venous insufficiency? * A. Intermittent claudication * B. Dependent edema * C. Cool, pale skin * D. Thickened toenails
- Correct: B. Dependent edema Dependent edema is a hallmark of venous insufficiency, caused by increased venous pressure and fluid leakage. * Incorrect: A. Intermittent claudication This is associated with arterial insufficiency. * Incorrect: C. Cool, pale skin These symptoms suggest arterial disease. * Incorrect: D. Thickened toenails Thickened toenails are not a primary sign of venous insufficiency.
