ch43.doc

[Osborn] chapter 43

Learning Outcomes [Number and Title ]Learning Outcome 1 Describe the risk factors and clinical findings in peripheral

arterial disease.Learning Outcome 2 Develop a nursing care plan for the patient with peripheral

arterial disease.Learning Outcome 3 Compare and contrast the clinical findings and management of

Raynaud’s disease and Buerger’s disease.Learning Outcome 4 Discuss signs and symptoms of common potential

complications of endovascular repair and surgery of the aorta, and appropriate nursing interventions for each.

Learning Outcome 5 Identify the risk factors, diagnosis, medical management, and nursing care for deep venous thrombosis.

Learning Outcome 6 Explain the actions of commonly used anticoagulants and antiplatelet agents used for patients with peripheral arterial disease and nursing management of the patient receiving them.

Learning Outcome 7 Identify the risk factors, diagnosis, medical management, and nursing care for varicose veins.

Learning Outcome 8 Identify the risk factors, diagnosis, medical management, and nursing care for aortic aneurysm and aortic dissection.

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice Copyright 2010 by Pearson Education, Inc.

1. The 65-year-old male client arrives in the clinic complaining of numbness and tingling of the lower extremities and pain in the legs upon exercise. The nurse asks which of the following questions to determine other risk factors this client may have for peripheral arterial disease?

Select all that apply.

1. “Do you smoke?”2. “Are you diabetic?”3. “Are you married?”4. “Do you exercise?”5. “Where were you born?”

Correct Answer:1. “Do you smoke?”2. “Are you diabetic?”

Rationale: “Do you smoke?” Smoking is a risk factor for peripheral arterial disease (PAD). “Are you diabetic?” Diabetes is a risk factor for peripheral arterial disease (PAD). “Are you married?” Marital status is not a risk factor for PAD. “Do you exercise?” Exercise may help to delay the symptoms of PAD. “Where were you born?” Birthplace is not a risk factor for PAD.

Cognitive Level: ApplicationNursing Process: AssessmentClient Need: Physiological Integrity LO: 1


2. The client who has just been diagnosed with peripheral arterial disease (PAD) asks what “intermittent claudication” means. The nurse’s best response is that intermittent claudication is:

1. Leg pain that happens with exercise.2. Leg pain that occurs at rest.3. Pain that can occur anywhere in the body with exercise.4. A tingling feeling in the hands.

Correct Answer: Leg pain that happens with exercise.

Rationale: Intermittent claudication is exercise-induced leg pain that can occur in different locations throughout the leg/hip area. While the pain can eventually occur at rest, the disease process has worsened significantly at that point. The pain is unique to the lower extremities.

Cognitive Level: ApplicationNursing Process: ImplementationClient Need: Health Promotion and MaintenanceLO: 1


3. A diabetic 68-year-old female client arrives at the clinic with a history of smoking, hypertension, family history of cardiac disease, COPD, and admits to rarely exercising. The nurse identifies which of the following risk factors most closely associated with peripheral arterial disease?

1. Hypertension and smoking2. COPD and family history of cardiac disease3. Sedentary lifestyle and diabetes4. Age and gender

Correct Answer: Hypertension and smoking

Rationale: Hypertension and smoking, along with diabetes, are the top risk factors for developing PAD. The other correlating factors are family history and sedentary lifestyle, but to a lesser degree. COPD and diabetes, as well as the client’s age and gender, are not closely related to development of PAD.

Cognitive Level: AnalysisNursing Process: AssessmentClient Need: Health Promotion and MaintenanceLO: 1


4. A client with peripheral arterial disease has a nursing diagnosis of Ineffective Tissue Perfusion. Which one of the following nursing interventions is most appropriate for this nursing diagnosis?

1. Do not elevate the client’s legs.2. Assist the client in taking hot baths.3. Encourage the client to limit activity.4. Limit visitors.

Correct Answer: Do not elevate the client’s legs.

Rationale: Keeping a client’s legs in the dependent position, and not elevating the legs, will help increase the arterial circulation. A client with PAD should avoid extremes in temperature and avoid a hot bath or cold weather. Activity should be encouraged, not discouraged. There is no need to limit visitors.

Cognitive Level: ApplicationNursing Process: ImplementationClient Need: Physiological IntegrityLO: 2


5. The client who has been diagnosed with PAD has a nursing diagnosis of Risk for Impaired Skin Integrity related to decreased peripheral circulation. Which of the following interventions is most appropriate for this client?

1. Instruct client on protecting the legs from injury because tissue is fragile and any wound is likely to heal slowly.

2. Instruct client on appropriate level of activity to promote circulation.3. Instruct client on risk factors that may increase problems with PAD.4. Instruct client on PAD signs and symptoms.

Correct Answer: Instruct client on protecting the legs from injury because tissue is fragile and any wound is likely to heal slowly.

Rationale: The client with risk for impaired skin integrity related to decreased peripheral circulation will need instruction on protecting the legs from injury. Any wound the client acquires is likely to heal slowly. The client will need instruction on the appropriate level of activity, risk factors, and signs and symptoms of PAD, but these do not relate to risk for impaired skin integrity.

Cognitive Level: AnalysisNursing Process: ImplementationClient Need: Physiological IntegrityLO: 2


6. A client with peripheral arterial disease (PAD) is a smoker. The nurse has established a nursing diagnosis of Deficient Knowledge of self-care needs and treatment plan related to tobacco use. Which one of the following interventions should the nurse choose to implement?

1. Discuss with the client a smoking cessation plan.2. Encourage the client to take medication.3. Instruct the client in increasing exercise.4. Discuss the client’s use of herbal therapies.

Correct Answer: Discuss with the client a smoking cessation plan.

Rationale: It is critical for the clients who smoke to stop smoking to improve their outcomes. A smoking cessation plan should be implemented and follow-up instituted after the client quits smoking. Medication, increasing exercise, and herbal therapies may be a part of the cessation plan.



7. A client with Raynaud’s disease presents with symptoms of pallor of the fingers. The client states that her hands turn white, then blue, then red. The nurse instructs the client that these symptoms are a result of:

1. The vasospasm of the small arteries and arterioles in the hands.2. Inflammation of the small vessels of the hands and feet with eventual

formation of small clots.3. Atherosclerosis caused by too many circulating lipids.4. Bleeding in the interior portion of the hands.

Correct Answer: The vasospasm of the small arteries and arterioles in the hands.

Rationale: A client with Raynaud’s disease has symptoms from vasospasm of the small arteries and arterioles in the hands. Inflammation of the small vessels of the hands and feet, with eventual formation of small clots, is the cause of Buerger’s disease. Neither Buerger’s nor Raynaud’s is caused by atherosclerosis or bleeding.



8. The nurse notes that the client with Raynaud’s disease is more anxious than usual and states, “I don’t understand why my hands keep turning colors. It seems to happen when I get upset. ” The nurse’s most appropriate response is to:

1. Discuss how stress can cause the vasospasms in Raynaud’s disease and develop a plan to manage stress.

2. Discuss using hot water to warm up the client’s hands and keep them warm.3. Implement a no-visitor policy to keep the client calmer.4. Discuss how Raynaud’s can impact the client’s health.

Correct Answer: Discuss how stress can cause the vasospasms in Raynaud’s disease and develop a plan to manage stress.

Rationale: Stress is related to Raynaud’s symptoms, and the client should be taught how to manage stress. The client should know how to keep the hands warm, but hot water is not advised. There is no need to implement a no-visitor policy; the client must learn to manage everyday stressors in order to manage the disease.



9. A 48-year-old male who smokes has just been diagnosed with Buerger’s disease. The nurse’s top priority prior to discharge of this client is to instruct the client on:

1. Smoking cessation.2. Avoiding hot climates.3. Increasing the client’s activity level.4. Decreasing the client’s anxiety.

Correct Answer: Smoking cessation.

Rationale: Buerger’s disease is primarily affiliated with the use of tobacco products; therefore, the nurse’s primary focus is providing instruction on smoking cessation and avoidance of all tobacco products. The client may also need to avoid cold temperature, which may make the symptoms worse. Increasing the client’s activity level and decreasing the client’s anxiety are not a top priority.



10. The client is scheduled for an endovascular repair. The nurse is providing preoperative instructions for this procedure. The client asks where the incision will be located. The nurse replies:

1. There will be a small incision in the groin area because the procedure is done via the femoral artery.

2. There will be an incision in the abdomen because the surgeon will need access to the abdomen.

3. There will be an incision in the mid-chest because the surgeon will need to perform bypass surgery.

4. There will be no incisions because the repair is done via IV access.

Correct Answer: There will be a small incision in the groin area because the procedure is done via the femoral artery.

Rationale: The endovascular repair is completed via the femoral artery, so a small incision in the groin may be necessary. Depending upon the location of the aneurysm, the surgeon may need access to different locations, which would require an open surgical repair. These surgeries are not considered endovascular. There is never a repair utilizing an IV access, since this is on the venous side, not the arterial.



11. A client who has just completed an endovascular repair of the aorta is now complaining of numbness and tingling in his toes. The nurse inspects the client’s legs and discovers weak pulses bilaterally, cool lower extremities, and capillary refill greater than 3 seconds. The nurse should immediately:

1. Contact the health care provider because the client has likely developed a thrombus, blocking the artery.

2. Contact the client’s family to come to the hospital.3. Instruct the client to take deep breaths to increase oxygenation.4. Contact the ECG technician to get an ECG because the client is likely having

a heart attack.

Correct Answer: Contact the health care provider because the client has likely developed a thrombus, blocking the artery.

Rationale: Because the client is experiencing numbness, tingling, weak pulses, and signs of poor perfusion, the client is likely experiencing a thrombus that is blocking the femoral arteries. The health care provider will need to be contacted immediately to evaluate the client. Contacting the client’s family should only be done if the client wishes, but this is not the priority. Instructing the client to take deep breaths will increase oxygenation, but will not impact the blood flow to the lower extremities. The client is not having a heart attack; therefore, completing an ECG is not necessary.

Cognitive Level: AnalysisNursing Process: EvaluationClient Need: Physiological IntegrityLO: 4


12. A client who is a fresh postoperative endovascular repair is complaining of numbness and tingling in his right foot. The nurse checks for pedal pulses and finds one only in the left foot. The right foot is cool and pale. What is the next step for the nurse to take?

1. Contact the health care provider.2. Take the client’s blood pressure.3. Listen to the client’s lungs.4. Provide the client with pain medication.

Correct Answer: Contact the health care provider.

Rationale: The fresh postoperative client who has undergone an endovascular repair is at risk for distal embolization. The lack of pedal pulse and a cool, pale right foot is indicative of a clot, and the health care provider should be contacted. Taking the client’s blood pressure and assessing the lung sounds will need to be done, but are not a top priority. Providing the client with pain medication is not necessary at this time.



13. A client with a deep venous thrombosis (DVT) is going home on warfarin (Coumadin). The nurse instructs the client that lab work will need to be drawn frequently until the levels stabilize. For which lab results will the client’s warfarin need to be adjusted?

1. INR of 1.32. INR of 2.13. INR of 2.84. INR of 3.0

Correct Answer: INR of 1.3

Rationale: The ideal INR range for a client on warfarin is 2.0 to 3.0. An INR of 1.3 will require warfarin to be increased. The INRs of 2.1, 2.8, and 3.0 are within therapeutic range.

Cognitive Level: AnalysisNursing Process: EvaluationClient Need: Health Promotion and MaintenanceLO: 5


14. A number of clients on the unit are at risk for deep venous thrombosis (DVT). The client who has _____________ has the highest risk.

1. Had a hip replacement2. Had a mole removed3. Had dental surgery4. Pneumonia

Correct Answer: Had a hip replacement

Rationale: An orthopedic surgical client has a 40% to 60% risk of developing a DVT. A mole repair and dental surgery have minimal risks for DVT. A client with pneumonia has an increased risk for DVT due to immobility.

Cognitive Level: ApplicationNursing Process: AssessmentClient Need: Health Promotion and MaintenanceLO: 5


15. A 150-pound male 38-year-old client has been diagnosed with deep venous thrombosis (DVT). The client’s history includes recent cardiac bypass surgery, working in a pesticide plant, and hypertension. The family is asking what risk factors the client may have that put him at risk for DVTs. The nurse responds by telling the family that:

1. His recent surgery and prolonged immobilization are risk factors.2. His prior employment in the pesticide plant may have contributed to the DVT.3. The cause for DVTs is unknown, but probably is related to his weight.4. The client’s hypertension is a major contributor to the development of DVTs.

Correct Answer: His recent surgery and prolonged immobilization are risk factors.

Rationale: Prolonged immobilization and the recent heart surgery have contributed to the client’s DVTs. Obesity can contribute to developing DVTs, but this client’s weight is 150 pounds. Working in a pesticide plant has no known correlation to the development of DVTs. Hypertension does not play a direct role in DVTs.



16. A client on clopidogrel (Plavix) is receiving discharge instructions. The nurse correctly tells the client to:

1. Take the medication with food.2. Take the medication on an empty stomach.3. Have PT drawn frequently.4. Be aware of food interactions with the medication.

Correct Answer: Take the medication with food.

Rationale: Clopidogrel should be taken with food. A PT is drawn for warfarin, not clopidogrel. Food interactions are more common with warfarin. However, clopidogrel does interact with NSAIDs, diltiazem, vitamin A, and anticoagulants and should be monitored for drug efficacy.



17. A client is receiving enoxaparin (Lovenox). The client is scheduled for surgery. The nurse visits with the anesthesia care provider to ensure that the client:

1. Will not be receiving an epidural.2. Will have correct body alignment.3. Will not receive medications that interact with enoxaparin.4. Is informed of the procedure.

Correct Answer: Will not be receiving an epidural.

Rationale: An epidural is contraindicated with clients receiving enoxaparin. The surgical department will ensure correct body alignment. The nurse will ensure the client has received information regarding the procedure, but would not contact anesthesia regarding this. Medication interaction is not common with enoxaparin.



18. The client with DVT is receiving enoxaparin (Lovenox) and will be discharged with this drug. The nurse is providing discharge instructions for the client. Which of the following would be information the nurse will provide regarding enoxaparin?

1. Leave the air bubble in the syringe when injecting the medication.2. This drug is given IM.3. The client will need to return to the clinic weekly to have lab work drawn.4. The client will need to inject this drug every 2 to 4 hours.

Correct Answer: Leave the air bubble in the syringe when injecting the medication.

Rationale: The enoxaparin comes prepackaged with a bubble already in the syringe. The bubble needs to remain in the syringe when injected so that the medication is all given into the tissue. Enoxaparin is given subcutaneous, not intramuscular. No lab work is required for enoxaparin on an ongoing basis. Enoxaparin is typically given one to two times per day.



19. The nurse is conducting a community class on the prevention of varicose veins. The nurse discusses which of the following with the class?

1. Avoid long periods of standing or sitting in one position.2. Gaining weight may help with minimizing risks of varicose veins.3. Place the feet in a dependent position to help with circulation.4. Avoid exercise such as walking that might increase stress on the legs.

Correct Answer: Avoid long periods of standing or sitting in one position.

Rationale: The nurse should advise the class to avoid any activity that will create pooling of the venous system, such as sitting or standing for extended periods of time. The client should also lose weight if appropriate, not gain weight. Placing the feet in a dependent position will help with arterial circulation, not venous. Intermittent exercise will help increase venous return.

Cognitive Level: AnalysisNursing Process: ImplementationClient Need: Health Promotion and MaintenanceLO: 7


20. A client who is pondering having surgical repair of varicose veins asks the nurse how long the hospital stay would be with that procedure. The nurse responds:

1. The procedure is performed as an outpatient. There is no inpatient stay.2. The procedure is completed over several days. The client will be asked to

come back every day to an outpatient setting.3. The procedure is an inpatient procedure that requires an overnight stay.4. The procedure is a complicated procedure and will require at least 2 days in

the hospital.

Correct Answer: The procedure is performed as an outpatient. There is no inpatient stay.

Rationale: Surgical repair of varicose veins is usually a one-time outpatient procedure and does not require inpatient care.



21. The nurse is educating a group of individuals on varicose veins. The nurse is asked how someone can avoid getting varicose veins. The nurse tells the group:

1. The best method to avoid varicose veins is to prevent them by maintaining ideal body weight, avoiding prolonged standing, and getting regular exercise.

2. Getting varicose veins is hereditary, so nothing a person does can stop them.3. Varicose veins are the result of blocked arteries, so increasing exercise will help.4. Wearing tight clothing will help prevent varicose veins.

Correct Answer: The best method to avoid varicose veins is to prevent them by maintaining ideal body weight, avoiding prolonged standing, and getting regular exercise.

Rationale: Avoiding prolonged standing, maintaining an ideal body weight, and getting regular exercise is the best way to prevent varicose veins. Heredity does play a role in varicose veins, but a client may still be able to minimize them. Varicose veins are not the result of blocked arteries. Wearing tight clothing may increase the likelihood of varicose veins.



22. The client presents to the emergency department (ED) with sharp pain between the shoulder blades. The client describes the pain as a “shredding” pain. The nurse recognizes that this problem often mimics a myocardial infarction (MI) or pulmonary embolism (PE). She knows that, unlike an MI client, this client will likely have which of the following tests performed?

1. CT scan of the chest/abdomen2. Troponin3. ECG4. Echocardiogram

Correct Answer: CT scan of the chest/abdomen

Rationale: A CT scan of the chest/abdominal area will reveal a dissecting aneurysm, but is not helpful for determination of an MI. Troponin and ECG will be done to rule out an MI. An echocardiogram may be done for both an MI or dissecting aneurysm.

Cognitive Level: ApplicationNursing Process: PlanningClient Need: Physiological IntegrityLO: 8


23. A client who has had a dissecting aneurysm repaired is being prepared for discharge. The client has a history of hypertension. The nurse is careful to explain to the client the importance of:

Select all that apply.

1. Keeping the blood pressure well managed.2. Not running out of blood pressure medication.3. Taking the client’s pulse.4. Managing the incision.5. Not drinking too much fluid.

Correct Answer:1. Keeping the blood pressure well managed.2. Not running out of blood pressure medication.

Rationale: Keeping the blood pressure well managed. It is critical to keep the client’s blood pressure under control. Not running out of blood pressure medication. It is critical for the client to take medication as instructed. Taking the client’s pulse. Taking the client’s pulse should not be an issue. Managing the incision. Managing an incision should not be an issue. Not drinking too much fluid. There isn’t likely to be a fluid restriction for the client.



24. A client presents to the emergency department with complaints of “feeling like something is ripping in my chest” and sudden onset of mid-back pain. The client has a history of hypertension. What is the top priority for this client?

1. Facilitate an immediate CT scan.2. Provide pain medication.3. Contact the client’s family.4. Obtain a surgical history.

Correct Answer: Facilitate an immediate CT scan.

Rationale: Rapid diagnosis for this client is imperative and may mean the difference between life and death. Facilitating an immediate CT or other diagnostic study will help with a diagnosis. The client will need pain medication, but it can be provided after the CT arrangements have been made. Contacting the client’s family and obtaining a surgical history are not top priorities for this client, but will need to also be accomplished.



ch43.doc

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