Ch.26 (PVD,Aneuysms) TB exam 2024/2025 with 100% correct answers
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Course
Ch.26 TB
Institution
Ch.26 TB
1. The nurse is taking a health history of a new client who reports pain in the left lower leg and foot when walking. This pain is relieved with rest, and the nurse observes that the left lower leg is slightly edematous and is hairless. When planning this client's care, the nurse should most likely...
1. The nurse is taking a health history of a new client who reports pain in the left lower leg and foot
when walking. This pain is relieved with rest, and the nurse observes that the left lower leg is slightly
edematous and is hairless. When planning this client's care, the nurse should most likely address which
health problem?
A. Coronary artery disease (CAD)
B. Intermittent claudication
C. Arterial embolus
D. Raynaud disease correct answersANS: B
Rationale: A muscular, cramp-type pain in the extremities consistently reproduced with the same degree
of exercise or activity and relieved by rest is experienced by clients with peripheral arterial insufficiency.
Referred to as intermittent claudication, this pain is caused by the inability of the arterial system to
provide adequate blood flow to the tissues in the face of increased demands for nutrients and oxygen
during exercise. The nurse would not suspect the client has CAD, arterial embolus, or Raynaud disease;
none of these health problems produce this cluster of signs and symptoms.
TOP: Chapter 26: Assessment and Management of Clients with Vascular Disorders and Disorders of
Peripheral Circulation KEY: Integrated Process: Nursing Process
2. While assessing a client, the nurse notes that the client's ankle-brachial index (ABI) of the right leg is
0.40. How should the nurse best follow up this assessment finding?
A. Assess the client's use of over-the-counter dietary supplements.
B. Implement interventions relevant to arterial narrowing.
C. Encourage the client to increase intake of foods high in vitamin K.
D. Adjust the client's activity level to accommodate decreased coronary output. correct answersANS: B
,Rationale: ABI is used to assess the degree of stenosis of peripheral arteries. An ABI of less than 1.0
indicates possible claudication of the peripheral arteries. It does not indicate inadequate coronary
output. There is no direct indication for changes in vitamin K intake and over-the-counter (OTC)
medications are not likely causative.
PTS: 1 REF: p. 824
NAT: Client Needs: Safe, Effective Care Environment: Management of Care
TOP: Chapter 26: Assessment and Management of Clients with Vascular Disorders and Disorders of
Peripheral Circulation KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Apply NOT: Multiple Choice
3. The nurse is admitting a 32-year-old woman to the presurgical unit. The nurse learns during the
admission assessment that the client takes oral contraceptives. The nurse's postoperative plan of care
should include what intervention?
A. Early ambulation and leg exercises
B. Cessation of the oral contraceptives until 3 weeks' postoperative
C. Doppler ultrasound of peripheral circulation twice daily
D. Dependent positioning of the client's extremities when at rest correct answersANS: A
Rationale: Oral contraceptive use increases blood coagulability; with bed rest, the client may be at
increased risk of developing deep vein thrombosis. Leg exercises and early ambulation are among the
interventions that address this risk. Assessment of peripheral circulation is important, but Doppler
ultrasound may not be necessary to obtain these data. Dependent positioning increases the risk of
venous thromboembolism (VTE). Contraceptives are not normally discontinued to address the risk of VTE
in the short term.
PTS: 1 REF: p. 847
NAT: Client Needs: Safe, Effective Care Environment: Management of Care
TOP: Chapter 26: Assessment and Management of Clients with Vascular Disorders and Disorders of
Peripheral Circulation KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Apply NOT: Multiple Choice
, 4. A nurse is creating an education plan for a client with venous insufficiency. Which measure should the
nurse include in the plan?
A. Avoid normal stockings that are tight.
B. Limit activities, including walking.
C. Sleep with legs below heart level.
D. Refrain from using graduated compression stockings. correct answersANS: A
Rationale: Measures taken to prevent complications include avoiding tight-fitting socks and panty girdles;
maintaining activities, such as walking; sleeping with legs elevated; and using pressure stockings. Not
included in the teaching plan for venous insufficiency would be reducing activity, sleeping with legs
dependent, and avoiding pressure stockings. Each of these actions exacerbates venous insufficiency.
PTS: 1 REF: p. 853
NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential
TOP: Chapter 26: Assessment and Management of Clients with Vascular Disorders and Disorders of
Peripheral Circulation KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Apply NOT: Multiple Choice
5. The nurse is caring for a client with a large venous leg ulcer. What intervention should the nurse
implement to promote healing and prevent infection?
A. Provide a high-calorie, high-protein diet.
B. Apply a clean occlusive dressing once daily and whenever soiled.
C. Abstain from wearing graduated compression stockings.
D. Apply an antibiotic ointment on the surrounding skin with each dressing change. correct answersANS:
A
Rationale: Wound healing is highly dependent on adequate nutrition. The diet should be sufficiently high
in calories and protein. Antibiotic ointments are not normally used on the skin surrounding a leg ulcer
and occlusive dressings can exacerbate impaired blood flow. Compression therapy should be
implemented with venous ulcers but not arterial ulcers.
PTS: 1 REF: p. 858
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