Question 1

The nurse is planning care for a client with peripheral vascular disease (PVD)who is at risk for Impaired Skin Integrity.Which intervention is appropriate for the nurse to include in the plan of care?
A) Restrict fluids.
B) Keep the skin clean and dry, and moisturize areas of dryness.
C) Encourage bed rest with legs elevated on pillows.
D) Consult a dietitian for low-protein diet.

Accepted Answer

A) The client with peripheral vascular disease who is at risk for impaired skin integrity should have meticulous skin care to keep the skin clean, dry, and well-moisturized to prevent skin breakdown. A low-protein diet is not beneficial for wound healing and may not be indicated for this client. A fluid restriction would dry tissues and not promote good skin turgor. Bed rest with legs elevated on pillows could increase the client's pain and would not help with preventing skin breakdown.
B) The client with peripheral vascular disease who is at risk for impaired skin integrity should have meticulous skin care to keep the skin clean, dry, and well-moisturized to prevent skin breakdown. A low-protein diet is not beneficial for wound healing and may not be indicated for this client. A fluid restriction would dry tissues and not promote good skin turgor. Bed rest with legs elevated on pillows could increase the client's pain and would not help with preventing skin breakdown.
C) The client with peripheral vascular disease who is at risk for impaired skin integrity should have meticulous skin care to keep the skin clean, dry, and well-moisturized to prevent skin breakdown. A low-protein diet is not beneficial for wound healing and may not be indicated for this client. A fluid restriction would dry tissues and not promote good skin turgor. Bed rest with legs elevated on pillows could increase the client's pain and would not help with preventing skin breakdown.
D) The client with peripheral vascular disease who is at risk for impaired skin integrity should have meticulous skin care to keep the skin clean, dry, and well-moisturized to prevent skin breakdown. A low-protein diet is not beneficial for wound healing and may not be indicated for this client. A fluid restriction would dry tissues and not promote good skin turgor. Bed rest with legs elevated on pillows could increase the client's pain and would not help with preventing skin breakdown.

Question 2

The nurse is assessing a client who is in the third trimester of pregnancy.Which finding would require immediate intervention by the nurse?
A) Blood pressure of 142/92 mmHg
B) Pulse of 92 beats per minute
C) Respiratory rate of 24 per minute
D) Weight gain of 16 oz per week

Accepted Answer

A) A pregnant client's blood pressure should not be greater than 140/90 mmHg, and if it is elevated, it could be a sign of gestational hypertension or preeclampsia. The pregnant client's heart and respiratory rates will increase slightly as a result of an increased circulatory volume and a decrease in intrathoracic space. Weight gain should average a pound per week in the second and third trimesters.
B) A pregnant client's blood pressure should not be greater than 140/90 mmHg, and if it is elevated, it could be a sign of gestational hypertension or preeclampsia. The pregnant client's heart and respiratory rates will increase slightly as a result of an increased circulatory volume and a decrease in intrathoracic space. Weight gain should average a pound per week in the second and third trimesters.
C) A pregnant client's blood pressure should not be greater than 140/90 mmHg, and if it is elevated, it could be a sign of gestational hypertension or preeclampsia. The pregnant client's heart and respiratory rates will increase slightly as a result of an increased circulatory volume and a decrease in intrathoracic space. Weight gain should average a pound per week in the second and third trimesters.
D) A pregnant client's blood pressure should not be greater than 140/90 mmHg, and if it is elevated, it could be a sign of gestational hypertension or preeclampsia. The pregnant client's heart and respiratory rates will increase slightly as a result of an increased circulatory volume and a decrease in intrathoracic space. Weight gain should average a pound per week in the second and third trimesters.

Question 3

A home care nurse is applying an Unna boot on a client with a stasis ulcer.Which statement will the nurse include when providing client education regarding this therapy?
A) "A nurse will change this dressing every 2 days."
B) "It is important that you maintain strict bed rest."
C) "The dressing will be applied to the entire length of your leg."
D) "The dressing I am applying is semi-rigid."

Accepted Answer

A) The Unna boot therapy is a semi-rigid dressing used to treat stasis ulcers. The dressing will be changed every 1-2 weeks, depending on ulcer drainage. The dressing allows a client to be ambulatory and does not make the client maintain strict bed rest. The dressing covers the lower leg and part of the thigh but not the entire leg.
B) The Unna boot therapy is a semi-rigid dressing used to treat stasis ulcers. The dressing will be changed every 1-2 weeks, depending on ulcer drainage. The dressing allows a client to be ambulatory and does not make the client maintain strict bed rest. The dressing covers the lower leg and part of the thigh but not the entire leg.
C) The Unna boot therapy is a semi-rigid dressing used to treat stasis ulcers. The dressing will be changed every 1-2 weeks, depending on ulcer drainage. The dressing allows a client to be ambulatory and does not make the client maintain strict bed rest. The dressing covers the lower leg and part of the thigh but not the entire leg.
D) The Unna boot therapy is a semi-rigid dressing used to treat stasis ulcers. The dressing will be changed every 1-2 weeks, depending on ulcer drainage. The dressing allows a client to be ambulatory and does not make the client maintain strict bed rest. The dressing covers the lower leg and part of the thigh but not the entire leg.

Question 4

The nurse is assessing a client who is 20 weeks pregnant.Which health issue should the nurse recognize as increasing this client's risk for the development of eclampsia?
A) Treatment for vitamin D deficiency
B) Surgery for ruptured appendix 1 year prior
C) Fibrocystic breast disease
D) Obesity

Accepted Answer

A) Risk factors for the development of eclampsia include obesity. The other choices will not predispose the client to developing eclampsia.
B) Risk factors for the development of eclampsia include obesity. The other choices will not predispose the client to developing eclampsia.
C) Risk factors for the development of eclampsia include obesity. The other choices will not predispose the client to developing eclampsia.
D) Risk factors for the development of eclampsia include obesity. The other choices will not predispose the client to developing eclampsia.

Question 5

A client is admitted to the hospital in order to have surgical intervention due to peripheral vascular disease (PVD).Which procedure is the likely intervention?
A) Stent placement
B) Endarterectomy
C) Percutaneous transluminal angioplasty
D) Atherectomy

Accepted Answer

A) Surgical intervention for PVD includes endarterectomy and bypass grafts. All other choices are non-surgical interventions for PVD.
B) Surgical intervention for PVD includes endarterectomy and bypass grafts. All other choices are non-surgical interventions for PVD.
C) Surgical intervention for PVD includes endarterectomy and bypass grafts. All other choices are non-surgical interventions for PVD.
D) Surgical intervention for PVD includes endarterectomy and bypass grafts. All other choices are non-surgical interventions for PVD.

Question 6

A client diagnosed with peripheral vascular disease (PVD)is obese,has a 30-year history of cigarette smoking,and works as a contractor.When discussing risk factors for PVD,which statement by the nurse is appropriate?
A) "Nicotine is a vasoconstrictor."
B) "Obesity is a factor in cardiovascular disease but not peripheral vascular disease."
C) "Nicotine primarily affects coronary arteries and the lungs."
D) "Your current occupation is a major risk factor."

Accepted Answer

A) The vasoconstrictive properties of nicotine will worsen the client's (PVD) by further decreasing peripheral blood flow. One of the most important parts of treatment is the cessation of cigarette smoking. The client's occupation is not a risk factor related to PVD. Obesity is a risk factor for both cardiovascular as well as PVD; however, the nurse should focus on smoking cessation as a first priority with this client.
B) The vasoconstrictive properties of nicotine will worsen the client's (PVD) by further decreasing peripheral blood flow. One of the most important parts of treatment is the cessation of cigarette smoking. The client's occupation is not a risk factor related to PVD. Obesity is a risk factor for both cardiovascular as well as PVD; however, the nurse should focus on smoking cessation as a first priority with this client.
C) The vasoconstrictive properties of nicotine will worsen the client's (PVD) by further decreasing peripheral blood flow. One of the most important parts of treatment is the cessation of cigarette smoking. The client's occupation is not a risk factor related to PVD. Obesity is a risk factor for both cardiovascular as well as PVD; however, the nurse should focus on smoking cessation as a first priority with this client.
D) The vasoconstrictive properties of nicotine will worsen the client's (PVD) by further decreasing peripheral blood flow. One of the most important parts of treatment is the cessation of cigarette smoking. The client's occupation is not a risk factor related to PVD. Obesity is a risk factor for both cardiovascular as well as PVD; however, the nurse should focus on smoking cessation as a first priority with this client.

Question 7

A nurse is caring for a client with venous stasis whose lower extremities have a brown pigmentation appearance.Which is this pigmentation appearance best attributed to?
A) The necrosis of subcutaneous fat due to tissue hypoxia
B) Breakdown of red blood cells in the congested tissues
C) The inflammatory and immune response from congested circulation
D) Skin atrophy caused by lack of circulation

Accepted Answer

A) Breakdown of red blood cells in the congested tissues causes brown skin pigmentation. While the other choices may occur with PVD, they are not responsible for the cause of brown pigmentation to the skin.
B) Breakdown of red blood cells in the congested tissues causes brown skin pigmentation. While the other choices may occur with PVD, they are not responsible for the cause of brown pigmentation to the skin.
C) Breakdown of red blood cells in the congested tissues causes brown skin pigmentation. While the other choices may occur with PVD, they are not responsible for the cause of brown pigmentation to the skin.
D) Breakdown of red blood cells in the congested tissues causes brown skin pigmentation. While the other choices may occur with PVD, they are not responsible for the cause of brown pigmentation to the skin.

Question 8

The community nurse is caring for a client who is 32 weeks pregnant and diagnosed with preeclampsia.Which statement indicates that the client requires additional teaching?
A) "My urine may become darker and smaller in amount each day."
B) "I should call the doctor if I develop a headache or blurred vision."
C) "Pain in the top of my abdomen is a sign my condition is worsening."
D) "Lying on my left side as much as possible is good for the baby."

Accepted Answer

A) Oliguria is a complication of preeclampsia caused by renal involvement and is a sign that the condition is worsening. It is not an expected outcome and should be reported to the physician. Headache and blurred vision or other visual disturbances are an indication of worsening preeclampsia, and should be reported to the physician. Left lateral position maximizes uterine and renal blood flow, and therefore is the optimal position for a client with preeclampsia. Epigastric pain is an indication of liver enlargement, a symptom of worsening preeclampsia, and should be reported to the physician.
B) Oliguria is a complication of preeclampsia caused by renal involvement and is a sign that the condition is worsening. It is not an expected outcome and should be reported to the physician. Headache and blurred vision or other visual disturbances are an indication of worsening preeclampsia, and should be reported to the physician. Left lateral position maximizes uterine and renal blood flow, and therefore is the optimal position for a client with preeclampsia. Epigastric pain is an indication of liver enlargement, a symptom of worsening preeclampsia, and should be reported to the physician.
C) Oliguria is a complication of preeclampsia caused by renal involvement and is a sign that the condition is worsening. It is not an expected outcome and should be reported to the physician. Headache and blurred vision or other visual disturbances are an indication of worsening preeclampsia, and should be reported to the physician. Left lateral position maximizes uterine and renal blood flow, and therefore is the optimal position for a client with preeclampsia. Epigastric pain is an indication of liver enlargement, a symptom of worsening preeclampsia, and should be reported to the physician.
D) Oliguria is a complication of preeclampsia caused by renal involvement and is a sign that the condition is worsening. It is not an expected outcome and should be reported to the physician. Headache and blurred vision or other visual disturbances are an indication of worsening preeclampsia, and should be reported to the physician. Left lateral position maximizes uterine and renal blood flow, and therefore is the optimal position for a client with preeclampsia. Epigastric pain is an indication of liver enlargement, a symptom of worsening preeclampsia, and should be reported to the physician.

Question 9

The nurse identifies assessment findings for an African-American client with preeclampsia.Blood pressure is 158/100 mmHg; urinary output 50 mL/hour; lungs clear to auscultation; urine protein 1+; 1+ edema hands,feet,ankles.On the next hourly assessment,which new assessment finding would indicate worsening of the condition?
A) Blood pressure 158/100 mmHg
B) Platelet count 150,000
C) Urinary output 20 mL/hour
D) Reflexes 2+

Accepted Answer

A) The decrease in urine output is an indication of decrease in glomerular filtration rate, which indicates a loss of renal perfusion. The assessment finding most abnormal and life-threatening is the urine output change. The blood pressure increase is not significant. The reflexes are normal at 2+. The platelet count is normal, though it is at the lower end.
B) The decrease in urine output is an indication of decrease in glomerular filtration rate, which indicates a loss of renal perfusion. The assessment finding most abnormal and life-threatening is the urine output change. The blood pressure increase is not significant. The reflexes are normal at 2+. The platelet count is normal, though it is at the lower end.
C) The decrease in urine output is an indication of decrease in glomerular filtration rate, which indicates a loss of renal perfusion. The assessment finding most abnormal and life-threatening is the urine output change. The blood pressure increase is not significant. The reflexes are normal at 2+. The platelet count is normal, though it is at the lower end.
D) The decrease in urine output is an indication of decrease in glomerular filtration rate, which indicates a loss of renal perfusion. The assessment finding most abnormal and life-threatening is the urine output change. The blood pressure increase is not significant. The reflexes are normal at 2+. The platelet count is normal, though it is at the lower end.

Question 10

A client with preeclampsia begins to seize.Which intervention by the nurse is most likely to protect the client and fetus from injury?
A) Elevate the client's legs.
B) Place the client on the left side and protect the airway.
C) Place the client in the supine position.
D) Elevate the head of the bed.

Accepted Answer

A) The client should be placed on the side to aid in circulation to the placenta. The airway needs to be maintained to ensure oxygenation throughout the seizure. The client should not be placed in the supine position. The head of the bed should not be elevated. The client's legs should not be elevated.
B) The client should be placed on the side to aid in circulation to the placenta. The airway needs to be maintained to ensure oxygenation throughout the seizure. The client should not be placed in the supine position. The head of the bed should not be elevated. The client's legs should not be elevated.
C) The client should be placed on the side to aid in circulation to the placenta. The airway needs to be maintained to ensure oxygenation throughout the seizure. The client should not be placed in the supine position. The head of the bed should not be elevated. The client's legs should not be elevated.
D) The client should be placed on the side to aid in circulation to the placenta. The airway needs to be maintained to ensure oxygenation throughout the seizure. The client should not be placed in the supine position. The head of the bed should not be elevated. The client's legs should not be elevated.

Question 11

A client admitted with chronic venous insufficiency has an infected wound of the left lower extremity.Which clinical manifestations does the nurse anticipate during the client's assessment? Select all that apply.
A) Pulses absent in the extremity with the wound
B) Wound that is pink with skin warm
C) Ulceration that is pale in color
D) Skin surrounding ulcer that is cool to the touch
E) Surrounding skin brown in color

Accepted Answer

A) Manifestations of a venous status ulcer would be a pink wound with warm skin and areas of hyperpigmentation. An ulcer that is pale in color with cool skin temperature and absent pulses is manifestations of arterial ulcers.
B) Manifestations of a venous status ulcer would be a pink wound with warm skin and areas of hyperpigmentation. An ulcer that is pale in color with cool skin temperature and absent pulses is manifestations of arterial ulcers.
C) Manifestations of a venous status ulcer would be a pink wound with warm skin and areas of hyperpigmentation. An ulcer that is pale in color with cool skin temperature and absent pulses is manifestations of arterial ulcers.
D) Manifestations of a venous status ulcer would be a pink wound with warm skin and areas of hyperpigmentation. An ulcer that is pale in color with cool skin temperature and absent pulses is manifestations of arterial ulcers.
E) Manifestations of a venous status ulcer would be a pink wound with warm skin and areas of hyperpigmentation. An ulcer that is pale in color with cool skin temperature and absent pulses is manifestations of arterial ulcers.

Question 12

The nurse is planning care for an older adult client with chronic venous insufficiency.Which will the nurse include in the client's teaching plan?
A) Keep the legs dependent as much as possible and elevate only when asleep.
B) Wear elastic hose as prescribed.
C) Standing will prevent the progression of the disease.
D) Cross legs only at the knees.

Accepted Answer

A) Care and treatment of a client with peripheral vascular disease includes instruction. The nurse should instruct the client to wear elastic hose as prescribed. The nurse should instruct the client to avoid sitting or standing for long periods of time. The legs should be elevated during rest and when asleep. Crossing the legs should be avoided.
B) Care and treatment of a client with peripheral vascular disease includes instruction. The nurse should instruct the client to wear elastic hose as prescribed. The nurse should instruct the client to avoid sitting or standing for long periods of time. The legs should be elevated during rest and when asleep. Crossing the legs should be avoided.
C) Care and treatment of a client with peripheral vascular disease includes instruction. The nurse should instruct the client to wear elastic hose as prescribed. The nurse should instruct the client to avoid sitting or standing for long periods of time. The legs should be elevated during rest and when asleep. Crossing the legs should be avoided.
D) Care and treatment of a client with peripheral vascular disease includes instruction. The nurse should instruct the client to wear elastic hose as prescribed. The nurse should instruct the client to avoid sitting or standing for long periods of time. The legs should be elevated during rest and when asleep. Crossing the legs should be avoided.

Question 13

The nurse identifies the diagnosis of Risk for Injury as appropriate for a client with preeclampsia.Which should the nurse include in this client's plan of care?
A) Suggest family and friends phone frequently.
B) Place in a semiprivate room.
C) Provide stimulation with television and visitors.
D) Limit phone calls and visitors.

Accepted Answer

A) The client with preeclampsia who is at risk for injury needs to be placed in a private room near the nurses' station. The room should be a quiet, with phone calls and visitors limited. The semiprivate room might provide too much stimulation. Television and visitors should be limited to reduce stimulation. Frequent phone calls would provide too much stimulation and should be limited.
B) The client with preeclampsia who is at risk for injury needs to be placed in a private room near the nurses' station. The room should be a quiet, with phone calls and visitors limited. The semiprivate room might provide too much stimulation. Television and visitors should be limited to reduce stimulation. Frequent phone calls would provide too much stimulation and should be limited.
C) The client with preeclampsia who is at risk for injury needs to be placed in a private room near the nurses' station. The room should be a quiet, with phone calls and visitors limited. The semiprivate room might provide too much stimulation. Television and visitors should be limited to reduce stimulation. Frequent phone calls would provide too much stimulation and should be limited.
D) The client with preeclampsia who is at risk for injury needs to be placed in a private room near the nurses' station. The room should be a quiet, with phone calls and visitors limited. The semiprivate room might provide too much stimulation. Television and visitors should be limited to reduce stimulation. Frequent phone calls would provide too much stimulation and should be limited.

Question 14

A client with peripheral vascular disease (PVD)asks the nurse what types of exercise would improve the client's condition and overall health.Which type of exercise will the nurse include in the response to the client?
A) Bicycling
B) Weight lifting
C) Yoga
D) Jogging

Accepted Answer

A) Yoga is considered a complementary therapy used to reduce stress and improve circulation. Jogging, weight lifting, and bicycling may or may not help improve the client's diagnosis of PVD.
B) Yoga is considered a complementary therapy used to reduce stress and improve circulation. Jogging, weight lifting, and bicycling may or may not help improve the client's diagnosis of PVD.
C) Yoga is considered a complementary therapy used to reduce stress and improve circulation. Jogging, weight lifting, and bicycling may or may not help improve the client's diagnosis of PVD.
D) Yoga is considered a complementary therapy used to reduce stress and improve circulation. Jogging, weight lifting, and bicycling may or may not help improve the client's diagnosis of PVD.

Question 15

A client with peripheral vascular disease (PVD)is experiencing pain.Which nursing intervention addresses the client's pain?
A) Elevate legs in bed with pillows under the knees.
B) Keep the extremities warm with blankets.
C) Encourage to ambulate and stand on legs 4 times each day.
D) Apply cool compresses to the extremities.

Accepted Answer

A) The nurse should help keep the client's extremities warm with blankets, as heat promotes vasodilation and reduces pain. Cool compresses will constrict vessels and cause more pain. Encouraging the client to ambulate and stand on the legs 4 times each day may be too aggressive. Pillows should not be placed under the knees.
B) The nurse should help keep the client's extremities warm with blankets, as heat promotes vasodilation and reduces pain. Cool compresses will constrict vessels and cause more pain. Encouraging the client to ambulate and stand on the legs 4 times each day may be too aggressive. Pillows should not be placed under the knees.
C) The nurse should help keep the client's extremities warm with blankets, as heat promotes vasodilation and reduces pain. Cool compresses will constrict vessels and cause more pain. Encouraging the client to ambulate and stand on the legs 4 times each day may be too aggressive. Pillows should not be placed under the knees.
D) The nurse should help keep the client's extremities warm with blankets, as heat promotes vasodilation and reduces pain. Cool compresses will constrict vessels and cause more pain. Encouraging the client to ambulate and stand on the legs 4 times each day may be too aggressive. Pillows should not be placed under the knees.

Question 16

During a routine prenatal visit,a client who is 24 weeks pregnant has an increased blood pressure.The nurse identifies which nursing diagnosis as appropriate for the client at this time?
A) Risk for Fluid Volume Excess
B) Chronic Pain
C) Risk for Impaired Growth and Development
D) Constipation

Accepted Answer

A) The rise in blood pressure could be caused by fluid retention as seen in preeclampsia. The client would be at risk for fluid volume excess. The other nursing diagnoses are not appropriate for the client at this time.
B) The rise in blood pressure could be caused by fluid retention as seen in preeclampsia. The client would be at risk for fluid volume excess. The other nursing diagnoses are not appropriate for the client at this time.
C) The rise in blood pressure could be caused by fluid retention as seen in preeclampsia. The client would be at risk for fluid volume excess. The other nursing diagnoses are not appropriate for the client at this time.
D) The rise in blood pressure could be caused by fluid retention as seen in preeclampsia. The client would be at risk for fluid volume excess. The other nursing diagnoses are not appropriate for the client at this time.

Question 17

The nurse is providing postpartum care for a client who gave birth by cesarean section several hours ago.Which interventions are appropriate for this client within the first 48 hours after birth? Select all that apply.
A) Antihypertensives as prescribed
B) Frequent assessment of serum electrolytes
C) Oxygen 2 liters nasal cannula as prescribed
D) Seizure precautions
E) Vital sign assessment every 4 hours

Accepted Answer

A) Even though the client with preeclampsia usually improves rapidly after giving birth, seizures can still occur during the first 48 hours postpartum. The client may also continue to receive antihypertensives as prescribed. Nursing management during the postpartal period also includes vital sign assessment every 4 hours for 48 hours. The client's hematocrit should be assessed and not necessarily serum electrolytes. Oxygen is not usually indicated after delivery.
B) Even though the client with preeclampsia usually improves rapidly after giving birth, seizures can still occur during the first 48 hours postpartum. The client may also continue to receive antihypertensives as prescribed. Nursing management during the postpartal period also includes vital sign assessment every 4 hours for 48 hours. The client's hematocrit should be assessed and not necessarily serum electrolytes. Oxygen is not usually indicated after delivery.
C) Even though the client with preeclampsia usually improves rapidly after giving birth, seizures can still occur during the first 48 hours postpartum. The client may also continue to receive antihypertensives as prescribed. Nursing management during the postpartal period also includes vital sign assessment every 4 hours for 48 hours. The client's hematocrit should be assessed and not necessarily serum electrolytes. Oxygen is not usually indicated after delivery.
D) Even though the client with preeclampsia usually improves rapidly after giving birth, seizures can still occur during the first 48 hours postpartum. The client may also continue to receive antihypertensives as prescribed. Nursing management during the postpartal period also includes vital sign assessment every 4 hours for 48 hours. The client's hematocrit should be assessed and not necessarily serum electrolytes. Oxygen is not usually indicated after delivery.
E) Even though the client with preeclampsia usually improves rapidly after giving birth, seizures can still occur during the first 48 hours postpartum. The client may also continue to receive antihypertensives as prescribed. Nursing management during the postpartal period also includes vital sign assessment every 4 hours for 48 hours. The client's hematocrit should be assessed and not necessarily serum electrolytes. Oxygen is not usually indicated after delivery.

Question 18

A client with peripheral vascular disease (PVD)has symptoms of intermittent claudication.Which will the nurse include when teaching the client about intermittent claudication?
A) It causes pain that occurs during periods of inactivity.
B) It causes pain that increases when the legs are elevated and decreases when the legs are dependent.
C) It causes cramping or aching pain in the lower extremities and the buttocks that occurs with a predictable level of activity.
D) It is often described as a burning sensation in the lower legs.

Accepted Answer

A) Intermittent claudication is a cramping or aching pain in the calves of the legs, the thighs, and the buttocks that occurs with a predictable level of activity. The pain is often accompanied by weakness and is relieved by rest.
B) Intermittent claudication is a cramping or aching pain in the calves of the legs, the thighs, and the buttocks that occurs with a predictable level of activity. The pain is often accompanied by weakness and is relieved by rest.
C) Intermittent claudication is a cramping or aching pain in the calves of the legs, the thighs, and the buttocks that occurs with a predictable level of activity. The pain is often accompanied by weakness and is relieved by rest.
D) Intermittent claudication is a cramping or aching pain in the calves of the legs, the thighs, and the buttocks that occurs with a predictable level of activity. The pain is often accompanied by weakness and is relieved by rest.

Question 19

The nurse identifies the diagnosis Ineffective Peripheral Tissue Perfusion related to decreased arterial flow to extremities as appropriate for a client.Which activity will the nurse recommend in order to improve the client's blood flow?
A) Cross the legs at the knees when seated.
B) Use a heating pad to increase warmth.
C) Elevate the feet while reclining.
D) Position with the extremities dependent.

Accepted Answer

A) Positioning with the extremities dependent is correct because gravity promotes arterial flow to the dependent extremity, increasing tissue perfusion. Crossing the legs at the knees when seated is not recommended because this position compresses partially obstructed arteries and impairs blood flow. Elevating the feet while reclining is not recommended because elevating the feet works against gravity and will further impede blood flow. Using a heating pad to increase warmth is not recommended because external heating devices could increase the risk of burns in a client with impaired circulation and decreased sensation.
B) Positioning with the extremities dependent is correct because gravity promotes arterial flow to the dependent extremity, increasing tissue perfusion. Crossing the legs at the knees when seated is not recommended because this position compresses partially obstructed arteries and impairs blood flow. Elevating the feet while reclining is not recommended because elevating the feet works against gravity and will further impede blood flow. Using a heating pad to increase warmth is not recommended because external heating devices could increase the risk of burns in a client with impaired circulation and decreased sensation.
C) Positioning with the extremities dependent is correct because gravity promotes arterial flow to the dependent extremity, increasing tissue perfusion. Crossing the legs at the knees when seated is not recommended because this position compresses partially obstructed arteries and impairs blood flow. Elevating the feet while reclining is not recommended because elevating the feet works against gravity and will further impede blood flow. Using a heating pad to increase warmth is not recommended because external heating devices could increase the risk of burns in a client with impaired circulation and decreased sensation.
D) Positioning with the extremities dependent is correct because gravity promotes arterial flow to the dependent extremity, increasing tissue perfusion. Crossing the legs at the knees when seated is not recommended because this position compresses partially obstructed arteries and impairs blood flow. Elevating the feet while reclining is not recommended because elevating the feet works against gravity and will further impede blood flow. Using a heating pad to increase warmth is not recommended because external heating devices could increase the risk of burns in a client with impaired circulation and decreased sensation.

Question 20

The nurse is evaluating teaching provided to a client with peripheral vascular disease (PVD).Which client observation indicates teaching has been effective?
A) Sitting in a chair with a pillow behind knees
B) Washing the lower extremities with mild soap, drying the legs, and applying a light moisturizer
C) Sitting in a chair with left leg crossed over the right
D) Smoking a pipe instead of cigarettes

Accepted Answer

A) The client who is observed washing the legs with mild soap, drying the legs, and applying a moisturizer is putting into practice the instruction regarding peripheral vascular disease. Sitting in a chair with legs crossed or with a pillow behind the knees would indicate further instruction was needed. The client smoking a pipe instead of cigarettes needs additional instruction regarding the hazards of tobacco.
B) The client who is observed washing the legs with mild soap, drying the legs, and applying a moisturizer is putting into practice the instruction regarding peripheral vascular disease. Sitting in a chair with legs crossed or with a pillow behind the knees would indicate further instruction was needed. The client smoking a pipe instead of cigarettes needs additional instruction regarding the hazards of tobacco.
C) The client who is observed washing the legs with mild soap, drying the legs, and applying a moisturizer is putting into practice the instruction regarding peripheral vascular disease. Sitting in a chair with legs crossed or with a pillow behind the knees would indicate further instruction was needed. The client smoking a pipe instead of cigarettes needs additional instruction regarding the hazards of tobacco.
D) The client who is observed washing the legs with mild soap, drying the legs, and applying a moisturizer is putting into practice the instruction regarding peripheral vascular disease. Sitting in a chair with legs crossed or with a pillow behind the knees would indicate further instruction was needed. The client smoking a pipe instead of cigarettes needs additional instruction regarding the hazards of tobacco.

Quiz 16: Perfusion

The nurse is planning care for a client with peripheral vascular disease (PVD) who is at risk for Impaired Skin Integrity.Which intervention is appropriate for the nurse to include in the plan of care?

The nurse is assessing a client who is in the third trimester of pregnancy.Which finding would require immediate intervention by the nurse?

A home care nurse is applying an Unna boot on a client with a stasis ulcer.Which statement will the nurse include when providing client education regarding this therapy?

The nurse is assessing a client who is 20 weeks pregnant.Which health issue should the nurse recognize as increasing this client's risk for the development of eclampsia?

A client is admitted to the hospital in order to have surgical intervention due to peripheral vascular disease (PVD) .Which procedure is the likely intervention?

A client diagnosed with peripheral vascular disease (PVD) is obese,has a 30-year history of cigarette smoking,and works as a contractor.When discussing risk factors for PVD,which statement by the nurse is appropriate?

A nurse is caring for a client with venous stasis whose lower extremities have a brown pigmentation appearance.Which is this pigmentation appearance best attributed to?

The community nurse is caring for a client who is 32 weeks pregnant and diagnosed with preeclampsia.Which statement indicates that the client requires additional teaching?

A client with preeclampsia begins to seize.Which intervention by the nurse is most likely to protect the client and fetus from injury?

A client admitted with chronic venous insufficiency has an infected wound of the left lower extremity.Which clinical manifestations does the nurse anticipate during the client's assessment? Select all that apply.

The nurse is planning care for an older adult client with chronic venous insufficiency.Which will the nurse include in the client's teaching plan?

The nurse identifies the diagnosis of Risk for Injury as appropriate for a client with preeclampsia.Which should the nurse include in this client's plan of care?

A client with peripheral vascular disease (PVD) asks the nurse what types of exercise would improve the client's condition and overall health.Which type of exercise will the nurse include in the response to the client?

A client with peripheral vascular disease (PVD) is experiencing pain.Which nursing intervention addresses the client's pain?

During a routine prenatal visit,a client who is 24 weeks pregnant has an increased blood pressure.The nurse identifies which nursing diagnosis as appropriate for the client at this time?

The nurse is providing postpartum care for a client who gave birth by cesarean section several hours ago.Which interventions are appropriate for this client within the first 48 hours after birth? Select all that apply.

A client with peripheral vascular disease (PVD) has symptoms of intermittent claudication.Which will the nurse include when teaching the client about intermittent claudication?

The nurse identifies the diagnosis Ineffective Peripheral Tissue Perfusion related to decreased arterial flow to extremities as appropriate for a client.Which activity will the nurse recommend in order to improve the client's blood flow?

The nurse is evaluating teaching provided to a client with peripheral vascular disease (PVD) .Which client observation indicates teaching has been effective?