1.
4. An Ankle Brachial Index of 0.65 suggests moderate arterial vascular disease in a client who is experiencing intermittent claudication. A Doppler ultrasound is indicated for further evaluation. The bradycardic heart rate is acceptable in an athletic client with a normal blood pressure. The SpO2 is acceptable; the client has a smoking history.CN: Physiological adaptation;
CL: Analyze
2.
2. With each set of vital signs, the nurse should assess the dorsalis pedis and posterior tibial pulses. The nurse needs to ensure adequate perfu- sion to the lower extremity with the drop in blood pressure. I.V. fl uids, nasal cannula setting, and capil- lary refi ll are important to assess, however, priority is to determine the cause of drop in blood pressure and that adequate perfusion through the new graft is maintained.CN: Reduction of risk potential;
CL: Analyze
3.
1, 2, 3, 5. Maintaining skin integrity is impor- tant in preventing chronic ulcers and infections. The client should be taught to routinely inspect the skin on a daily basis. The client should reduce weight to promote circulation; a diet lower in calories and fat is appropriate. Because the client is receiving Cou- madin, the client is at risk for bleeding from cuts. To decrease the risk of cuts, the nurse should suggest that the client use an electric razor. The client with decreased arterial blood fl ow should be encouraged to participate in ADLs. In fact, the client should be encouraged to consult an exercise physiologist for an exercise program that enhances the aerobic capacity of the body.CN: Health promotion and maintenance;
CL: Synthesize
4.
4. Blood fl ows in a unidirectional man- ner, and the blood fl ow involves the differences in pressure between the arterial and venous systems.Billings_Part 2_Chap 3_Test 02.indd 357
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14.
2. Reduction of blood fl ow to a specifi c area results in decreased oxygen and nutrients. As a result, the skin may appear mottled. Loss of hair and cool, dry skin are other signs that the nurse may observe in a client with PVD of the lower extremities.CN: Health promotion and maintenance;
CL: Analyze
15.
3. Generally, a 50% to 75% occlusion in the arterial lumen causes symptoms associated with intermittent claudication. When the demand for oxy- gen becomes greater than the supply in the working muscle, the client experience pain (aching, cramping).When the individual sits down and rests, the demand and supply of oxygen become balanced and the dis- comfort dissipates. Occlusion of 100% would result in ischemia and necrosis of tissue distal to the artery and would require immediate surgical intervention.
CN: Reduction of risk potential;
CL: Analyze
16.
3. When pedal pulses are not palpable, the nurse should obtain a Doppler ultrasound device.Auscultation is not likely to be helpful if the pulse isn’t palpable. Inspection of the lower extremity can be done simultaneously when palpating, but the nurse should fi rst try to locate a pulse by Doppler.
Calling the physician may be necessary if there is a change in the client’s condition.
CN: Physiological adaptation;
CL: Synthesize
17.
2. The sound produced by the Doppler instrument refl ects all of the vascular structures in the path of the sound beam; therefore, it may be hard to differentiate between arterial and venous blood fl ow. Capillary and arteriole blood fl ow can- not be auscultated with a Doppler instrument.CN: Physiological adaptation; CL: Apply
18.
3. An increased LDL cholesterol concentra- tion has been documented as a risk factor for the development of atherosclerosis. LDL cholesterol is not broken down in the liver but is deposited into the intima of the blood vessels. Low triglyceride levels are desirable. High HDL and low LDL levels are benefi cial and are known to be protective for the cardiovascular system.CN: Reduction of risk potential; CL: Apply
19.
4. Coldness in the left foot and ankle is consistent with complete arterial obstruction. Other expected fi ndings would include paralysis and pallor. Aching pain, a burning sensation, or numb- ness and tingling are earlier signs of tissue hypoxia and ischemia and are commonly associated within incomplete obstruction.CN: Physiological adaptation;
CL: Analyze
10.
1. A client with PVD and heart failure will experience decreased blood fl ow. In this situation, low exercise tolerance (oxygen demand becomes greater than the oxygen supply) may be related to less blood being ejected from the left ventricle into the systemic circulation. Decreased blood supply to the tissues results in pain. Increased blood viscosity may be a component, but it is of much less impor- tance than the disease processes.CN: Reduction of risk potential;
CL: Synthesize
11.
4. In PVD, decreased blood fl ow can result in increased venous pressure. The increase in venous pressure results in an increase in capillary hydro- static pressure, which causes a net fi ltration of fl uid out of the capillaries into the interstitial space, result- ing in edema. Valves often become incompetent with PVD. Blood volume is not decreased in this condi- tion. Decreased muscular action would contribute to the formation of edema in the lower extremities.CN: Reduction of risk potential;
CL: Analyze
12.
4.The presence of a strong dorsalis pedis pulse indi- cates that there is circulation to the extremity distal to the surgery indicating that the graft between the femoral and popliteal artery is allowing blood to cir- culate effectively. Answer 1 shows the nurse obtain- ing the radial pulse; answer 2 shows the femoral pulse, which is proximal to the surgery site and will not indicate circulation distal to the surgery site.
Answer 3 shows the nurse obtaining an apical pulse.
CN: Reduction of risk potential;
CL: Analyze
13.
2. Age is a nonmodifi able risk factor for ath- erosclerosis. The nurse instructs the client to manage modifi able risk factors such as comorbid diseases (e.g., diabetes), activity level, and diet. Controlling serum blood glucose levels, engaging in regular aero- bic activity, and choosing a diet low in saturated fats can reduce the risk of developing atherosclerosis.CN: Health promotion and maintenance;
CL: Apply
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24.
3. The term gangrene refers to blackened, decomposing tissue that is devoid of circulation.Chronic ischemia and death of the tissue can lead to gangrene in the affected extremity. Injury, edema, and decreased circulation lead to infection, gangrene, and tissue death. Atrophy is the shrinking of tissue, and contraction is joint stiffening secondary to disuse.
The term rubor denotes a reddish color of the skin.
CN: Physiological adaptation;
CL: Analyze
25.
1. The ankle-brachial index is based on the ratio of the ankle systolic blood pressure to arm systolic blood pressure. It allows one to quantify the degree of arterial stenosis.CN: Reduction of risk potential;
CL: Analyze
26.
1. An arteriogram involves injecting a radiopaque contrast agent directly into the vascular system to visualize the vessels. It usually involves computed tomographic scanning. The velocity of the blood fl ow can be estimated by duplex ultrasound.The client’s ankle-brachial index is determined, and then the client is requested to walk. The normal response is little or no drop in ankle systolic pres- sure after exercise.
CN: Reduction of risk potential; CL: Apply
27.
2. Clients may have an immediate or a delayed reaction to the radiopaque dye. The physi- cian should be notifi ed immediately because the symptoms suggest an allergic reaction. Treatment may involve administering oxygen and epineph- rine. Explaining that the procedure is over does not address the current symptoms.CN: Physiological adaptation;
CL: Synthesize
28.
3. The client is at greater risk for skin break- down in the lower extremities related to the edema and to remaining in one position, which increases capillary pressure. Turning the client every 1 to 2 hours promotes vasodilation and prevents vascu- lar compression. Administering pain medication will not have an effect on skin integrity. Encourag- ing fl uids is not a direct intervention for maintaining skin integrity, although being well hydrated is a goal for most clients. Maintaining hygiene does infl uence skin integrity but is secondary in this situation.CN: Physiological adaptation;
CL: Synthesize
29.
4. The client should avoid using iodine or over-the-counter medications. Iodine is a highly toxic solution. An individual who has known PVD should be seen by a physician for treatment to avoid infection. The client with PVD should avoid heating pads and crossing the legs, and should wear leather20.
1. Anxiety stimulates the sympathetic nervous system, which results in the secretion of epinephrine, angiotensin, and serum proteins that cause vasoconstriction in the arteries of the periph- eral circulatory system. As a result, peripheral vas- cular resistance is increased. This vasoconstriction may increase pain in the areas where PVD is the greatest. The lymphatic system does not affect the blood supply of tissues.CN: Physiological adaptation; CL: Apply
21.
1. Activity intolerance related to decreased blood supply and pain is a common problem with clients experiencing claudication. The goal should be to educate the client to maintain his level of activity and incorporate frequent rest periods to pre- vent episodes of decreased blood supply. The data do not suggest that the client cannot perform self- care activities, is not coping with his chronic pain, or that his skin integrity is impaired. It should be appropriate to incorporate the nursing diagnosis of Risk for impaired skin integrity into the client’s plan of care.CN: Health promotion and maintenance;
CL: Analyze
22.
4. Incision site.
3. Urine output.
1. Postoperative pain.
2. Peripheral pulses.
Because assessment of the presence and quality of the pedal pulses in the affected extremity is essen- tial after surgery to make sure that the bypass graft is functioning, this step should be done fi rst. The nurse should next ensure that the dressing is intact, and then that the client has adequate urine output.
Lastly, the nurse should determine the client’s level of pain.
CN: Physiological adaptation;
CL: Synthesize
23.
1. Decreasing venous congestion in the extremities is a desired outcome for clients with heart failure. The nurse should elevate the client’s legs above the level of the heart to achieve this goal.The client is not demonstrating diffi culty breath- ing or being cold. The nurse should prevent injury to the swollen extremity; however, this is not the priority.
CN: Health promotion and maintenance;
CL: Synthesize
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34.
2. Encouraging the client who is undergoing amputation to verbalize feelings is the most thera- peutic nursing intervention. By eliciting concerns, the nurse may be able to provide information to help the client cope. The nurse should avoid value- laden responses, such as “You’ll still have one good leg,” that may make the client feel guilty or hostile and block further communication. The nurse should not ignore the client’s expressed concerns, nor should the nurse reinforce the client’s concern about invalidism and dependency or assume that his wife is willing to care for him.CN: Psychosocial adaptation;
CL: Synthesize
35.
2. The level of amputation commonly cannot be accurately determined until surgery, when the surgeon can directly assess the adequacy of the cir- culation of the residual limb. A longer residual limb facilitates prosthesis fi tting and will make it easier for the client to walk. However, although these aspects will be considered in the fi nal decision, they are not the primary factors infl uencing the decision.CN: Physiological adaptation;
CL: Synthesize
36.
1. Leg crossing is contraindicated because it causes adduction of the hips and decreases the fl ow of blood into the lower extremities. This may result in increased pressure in the graft in the affected leg.Elevating the legs, fl exing the ankles, and extending the knees are not necessarily contraindicated.
CN: Reduction of risk potential;
CL: Synthesize
37.
2. The client should be evaluated for hemo- dynamic stability and extent of bleeding prior to calling the physician. Direct pressure can be used prior to applying a tourniquet if there is signifi cant bleeding. To avoid fl exion contractures, which can delay rehabilitation, elevation of the surgical limb is contraindicated.CN: Reduction of risk potential;
CL: Synthesize
38.
3. The purpose of wrapping the stump is to shape the residual limb to accept a prosthesis and bear weight. The compression bandaging should be worn at all times for many weeks after surgery and should be reapplied as needed to keep it free of wrinkles and snug. The dressing should be changed daily to allow for inspection of the stump incision. No lotions should be applied to the stump unless specifi cally ordered by the physician. The stump should not be elevated on pillows because this will contribute to the formation of fl exion contractures. Contractures will prevent the client from wearing a prosthesis and ambulating.CN: Physiological adaptation;
CL: Evaluate shoes. A heating pad can cause injury, which,
because of the decreased blood supply, can be dif- fi cult to heal. Crossing the legs can further impede blood fl ow. Leather shoes provide better protection.
CN: Health promotion and maintenance;
CL: Evaluate
30.
1. Maintaining circulation in the affected extremity after surgery is the focus of care. The graft can become occluded, and the client must be assessed frequently to determine whether the graft is patent.Preventing infection and relieving pain are important but are secondary to maintaining graft patency. Edu- cation should have taken place in the preoperative phase and then continued during the recovery phase.
CN: Physiological adaptation;
CL: Synthesize
31.
1, 3. Elastic stockings (support hose) are used to promote circulation by preventing pooling of blood in the feet and legs. The stockings should be applied in the morning before the client gets out of bed. The stockings should be applied smoothly and to avoid wrinkles, but the top should not be rolled down to avoid constriction of circulation. The stock- ings should be removed every 8 hours and the client should elevate the legs for 15 minutes and reapply the stockings. Clean stockings should be applied daily or as needed.CN: Health promotion and maintenance;
CL: Create
32.
4. If surgery is scheduled, the nurse should avoid venipunctures in the affected extremity. The goal should be to prevent unnecessary trauma and possible infection in the affected arm. Disruptions in skin integrity and even minor skin irritations can cause the surgery to be canceled. The nurse can con- tinue to monitor the temperature and radial pulse in the affected arm; however, doing so is not the prior- ity. Keeping the client warm is important but is not the priority at this time.CN: Reduction of risk potential;
CL: Analyze
The Client with Peripheral Vascular Disease Having an Amputation
33.
2. Slow, steady walking is a recommended activity for clients with peripheral vascular disease because it stimulates the development of collateral circulation. The client with PVD should not remain inactive. Elevating the legs above the heart or wear- ing antiembolism stockings is a strategy for alleviat- ing venous congestion and may worsen peripheral arterial disease.CN: Basic care and comfort; CL: Evaluate
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with heparin, and the client’s PTT would need to be monitored closely if the client were taking heparin.
It does not affect cholesterol levels.
CN: Pharmacological and parenteral therapies; CL: Analyze
44.
2. Angina is an adverse reaction to pen- toxifylline, which should be used cautiously in clients with CAD. The nurse should report the client’s symptoms to the physician, who may order nitroglycerin and possibly discontinue the pentoxifylline. The client should rest until the chest pain subsides, and documentation is essential when a client experiences an adverse reaction with medications that have been prescribed; however, the nurse’s top priority is to call the physician, report the problem, and obtain an order for nitroglycerin.The client’s complaints should never be dismissed.
CN: Physiological adaptation;
CL: Synthesize
45.
1. Assessing the individual’s health behav- ior before surgery will help the nurse and client develop strategies to manage the postoperative course. Asking open-ended questions will illicit the most helpful information. The client’s ability to walk after surgery will be improved after surgery.The nurse can ask direct questions after obtaining general information.
CN: Health promotion and maintenance;
CL: Create
46.
4. Before beginning dietary interventions, the nurse must assess the client’s pattern of food intake, life style, food preferences, and ethnic, cultural, and fi nancial infl uences.CN: Basic care and comfort;
CL: Synthesize