Brunner and Suddarth's Textbook of Medical Surgical Nursing; Chapter
Assessment and Management of Patients With Vascular Disorders 2024
1. The nurse is taking a health history of a new patient. The patient reports
experiencing pain in his left lower leg and foot when walking. This pain is
relieved with rest. The nurse notes that the left lower leg is slightly edematous
and is hairless. When planning this patient's subsequent care, the nurse
should most likely address what health problem?
Feedback: A muscular, cramptype pain in the extremities consistently reproduced
with the same degree of exercise or activity and relieved by rest is experienced by
patients 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 patient has CAD,
arterial embolus, or Raynaud's disease; none of these health problems produce this
cluster of signs and symptoms.
2. While assessing a patient the nurse notes that the patient's
anklebrachial index (ABI) of the right leg is 0.40. How should the nurse best
respond to this assessment finding?
-- Assess the patient's use of overthecounter dietary supplements.
-- Implement interventions relevant to arterial narrowing.
--Encourage the patient to increase intake of foods high in vitamin K.
--Adjust the patient's activity level to accommodate decreased coronary
output.: Answer: implement interventions relevant to arterial narrowing.
Feedback: 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 OTC medications are not likely causative.
,3. The nurse is providing care for a patient who has just been diagnosed
with peripheral arterial occlusive disease (PAD). What assessment finding is
most consistent with this diagnosis?
- Numbness and tingling in the distal extremities
-Unequal peripheral pulses between extremities
-Visible clubbing of the fingers and toes
-Reddened extremities with muscle atrophy: Answer: Unequal peripheral pulses
between extremities
Feedback: PAD assessment may manifest as unequal pulses between
extremities, with the affected leg cooler and paler than the unaffected leg.
Intermittent claudication is far more common than sensations of numbness and
tingling. Clubbing and muscle atrophy are not associated with PAD.
4. The nurse is admitting a 32yearold woman to the presurgical unit. The
nurse learns during the admission assessment that the patient takes oral
contraceptives. Consequently, the nurse's postoperative plan of care should
include what intervention?
-Early ambulation and leg exercises
-Cessation of the oral contraceptives until 3 weeks postoperative
- Doppler ultrasound of peripheral circulation twice daily
-Dependent positioning of the patient's extremities when at rest: Answer:
Early ambulation and leg exercises
Feedback: Oral contraceptive use increases blood coagulability; with bed rest, the
patient 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.
, Brunner and Suddarth's Textbook of Medical Surgical Nursing; Chapter
Assessment and Management of Patients With Vascular Disorders 2024
5. A nurse is creating an education plan for a patient with venous
insufficiency. What measure should the nurse include in the plan?
-Avoiding tightfitting socks.
-Limit activity whenever possible.
-Sleep with legs in a dependent position.
-Avoid the use of pressure stockings.: answer: Avoiding tightfitting socks.
Feedback: Measures taken to prevent complications include avoiding tightfitting
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.
6. The nurse is caring for a patient with a large venous leg ulcer. What
intervention should the nurse implement to promote healing and prevent
infection?
-Provide a highcalorie, highprotein diet.
-Apply a clean occlusive dressing once daily and whenever soiled.
-Irrigate the wound with hydrogen peroxide once daily.
-Apply an antibiotic ointment on the surrounding skin with each dressing
change.: Answer: Provide a highcalorie, highprotein diet.
Feedback: 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. Hydrogen peroxide is not normally used because
it can damage granulation tissue.
7. The nurse is caring for a patient who returned from the tropics a few
weeks ago and who sought care with signs and symptoms of lymphedema.
The nurse's plan of care should prioritize what nursing diagnosis?
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