Question 1

A patient presents to the clinic complaining of the inability to grasp objects with her right hand. The patients right arm is cool and has a difference in blood pressure of more than $20 \mathrm{~mm} \mathrm{Hg}$ compared with her left arm. The nurse should expect that the primary care provider may diagnose the woman with what health problem?

Accepted Answer

The patient with upper extremity arterial occlusive disease typically complains of arm fatigue and pain with exercise (forearm claudication) and inability to hold or grasp objects (e.g., combing hair, placing objects on shelves above the head) and, occasionally, difficulty driving. Assessment findings include coolness and pallor of the affected extremity, decreased capillary refill, and a difference in arm blood pressures of more than $20 \mathrm{~mm} \mathrm{Hg}$. These symptoms are not closely associated with Raynauds or lymphedema. The upper extremities are rare sites for VTE.

Question 2

A nurse working in a long-term care facility is performing the admission assessment of a newly admitted, 85-year-old resident. During inspection of the residents feet, the nurse notes that she appears to have early evidence of gangrene on one of her great toes. The nurse knows that gangrene in the elderly is often the first sign of what?

Accepted Answer

In elderly people, symptoms of PAD may be more pronounced than in younger people. In elderly patients who are inactive, gangrene may be the first sign of disease. Venous insufficiency does not normally manifest with gangrene. Similarly, VTE and Raynauds phenomenon do not cause the ischemia that underlies gangrene.

Question 3

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? Select all that apply.

Accepted Answer

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 $\mathrm{D}$ and calcium do not address the main risk factors for VTE.

Question 4

The nurse is caring for an acutely ill patient who is on anticoagulant therapy. The patient has a comorbidity of renal insufficiency. How will this patients renal status affect heparin therapy?

Accepted Answer

If renal insufficiency exists, lower doses of heparin are required. Coumadin cannot be safely and effectively used as a substitute and there is no contraindication for IV administration.

Question 5

The nurse is assessing a woman who is pregnant at 27 weeks gestation. The patient is concerned about the recent emergence of varicose veins on the backs of her calves. What is the nurses best response?

Accepted Answer

Pregnancy may cause varicosities because of hormonal effects related to decreased venous outflow,
increased pressure by the gravid uterus, and increased blood volume. In most cases, no intervention or referral is necessary. This finding is not an indication for $\mathrm{ABI}$ assessment and increased activity will not likely resolve the problem.

Question 6

Graduated compression stockings have been prescribed to treat a patients venous insufficiency. What education should the nurse prioritize when introducing this intervention to the patient?

Accepted Answer

Any type of stocking can inadvertently become a tourniquet if applied incorrectly (i.e., rolled tightly at the top). In such instances, the stockings produce rather than prevent stasis. For ambulatory patients, graduated compression stockings are removed at night and reapplied before the legs are lowered from the bed to the floor in the morning. They are used daily, not on alternating days. Anticoagulants are not always indicated in patients who are using compression stockings.

Question 7

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?

Accepted Answer

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.

Question 8

How should the nurse best position a patient who has leg ulcers that are venous in origin?

Accepted Answer

Positioning of the legs depends on whether the ulcer is of arterial or venous origin. With venous insufficiency, dependent edema can be avoided by elevating the lower extremities. Dangling the patients legs and applying pillows may further compromise venous return.

Question 9

A patient with advanced venous insufficiency is confined following orthopedic surgery. How can the nurse best prevent skin breakdown in the patients lower extremities?

Accepted Answer

If the patient is on bed rest, it is important to relieve pressure on the heels to prevent pressure ulcerations, since the heels are among the most vulnerable body regions. Monitoring blood work does not directly prevent skin breakdown, even though albumin is related to wound healing. Massage is not normally indicated and may exacerbate skin breakdown. Passive range- of-motion exercises do not directly reduce the risk of skin breakdown.

Question 10

The nurse has performed a thorough nursing assessment of the care of a patient with chronic leg ulcers. The nurses assessment should include which of the following components? Select all that apply.

Accepted Answer

A careful nursing history and assessment are important. The extent and type of pain are carefully assessed, as are the appearance and temperature of the skin of both legs. The quality of all peripheral pulses is assessed, and the pulses in both legs are compared. Any limitation of mobility and activity that results from vascular insufficiency is identified. Not likely is there any direct indication for assessment of apical heart rate, although peripheral pulses must be assessed.

Question 11

A nurse on a medical unit is caring for a patient who has been diagnosed with lymphangitis. When reviewing this patients medication administration record, the nurse should anticipate which of the following?

Accepted Answer

Lymphangitis is an acute inflammation of the lymphatic channels caused by an infectious process. Antibiotics are always a component of treatment. Diuretics are of nominal use. Anticoagulants and antiplatelet aggregators are not indicated in this form of infection.

Question 12

A postsurgical patient has illuminated her call light to inform the nurse of a sudden onset of lower leg pain. On inspection, the nurse observes that the patients left leg is visibly swollen and reddened. What is the nurses most appropriate action?

Accepted Answer

VTE requires prompt medical follow-up. Heparin will not dissolve an established clot. Massaging the patients leg and mobilizing the patient would be contraindicated because they would dislodge the clot, possibly resulting in a pulmonary embolism.

Question 13

A nurse is closely monitoring a patient who has recently been diagnosed with an abdominal aortic aneurysm. What assessment finding would signal an impending rupture of the patients aneurysm?

Accepted Answer

Signs of impending rupture include severe back or abdominal pain, which may be persistent or intermittent. Impending rupture is not typically signaled by increased blood pressure, bradycardia, cessation of pulsing, or hemoptysis.

Question 14

A nurse is reviewing the physiological factors that affect a patients cardiovascular health and tissue oxygenation. What is the systemic arteriovenous oxygen difference?

Accepted Answer

The average amount of oxygen removed collectively by all of the body tissues is about $25 \%$. This means that the blood in the vena cava contains about $25 \%$ less oxygen than aortic blood. This is known as the systemic arteriovenous oxygen difference. The other answers do not apply.

Question 15

The nurse is evaluating a patients diagnosis of arterial insufficiency with reference to the adequacy of the patients blood flow. On what physiological variables does adequate blood flow depend? Select all that apply.

Accepted Answer

Adequate blood flow depends on the efficiency of the heart as a pump, the patency and responsiveness of the blood vessels, and the adequacy of circulating blood volume. Adequacy of blood flow does not primarily depend on the size of red cells or their ratio to the number of platelets.

Question 16

A nurse is assessing a new patient who is diagnosed with PAD. The nurse cannot feel the pulse in the patients left foot. How should the nurse proceed with assessment?

Accepted Answer

When pulses cannot be reliably palpated, a hand-held continuous wave (CW) Doppler ultrasound device may be used to hear (insonate) the blood flow in vessels. CT is not normally warranted and the
application of a tourniquet poses health risks and will not aid assessment. Elevating the extremity would make palpation more difficult.

Question 17

A medical nurse has admitted four patients over the course of a 12-hour shift. For which patient would assessment of ankle-brachial index (ABI) be most clearly warranted?

Accepted Answer

Nurses should perform a baseline ABI on any patient with decreased pulses or any patient 50 years of age or older with a history of diabetes or smoking. The other answers do not apply.

Question 18

An older adult patient has been treated for a venous ulcer and a plan is in place to prevent the occurrence of future ulcers. What should the nurse include in this plan?

Accepted Answer

A diet that is high in protein, vitamins $\mathrm{C}$ and $\mathrm{A}$, iron, and zinc is encouraged to promote healing and prevent future ulcers. Prophylactic antibiotics and saline compresses are not used to prevent ulcers. Oxygen supplementation does not prevent ulcer formation.

Question 19

A 79-year-old man is admitted to the medical unit with digital gangrene. The man states that his problems first began when he stubbed his toe going to the bathroom in the dark. In addition to this trauma, the nurse should suspect that the patient has a history of what health problem?

Accepted Answer

Arterial insufficiency may result in gangrene of the toe (digital gangrene), which usually is caused by trauma. The toe is stubbed and then turns black. Raynauds, CAD and varicose veins are not the usual causes of digital gangrene in the elderly.

Question 20

When assessing venous disease in a patients lower extremities, the nurse knows that what test will most likely be ordered?

Accepted Answer

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.

Quiz 30: Assessment and Management of Patients With Vascular Disorders and Problems of Peripheral Circulation