A nurse is collecting data from a client who has venous insufficiency. Which of the following findings should the nurse expect?
Thickened toenails
Shiny, thin skin on the lower extremities
Dusky, red color of the feet when dangling
Pitting edema
The Correct Answer is D
Choice A reason : Thickened toenails are often associated with fungal infections and are not a direct symptom of venous insufficiency. However, they can appear in patients with chronic venous insufficiency due to poor circulation that affects the health of the toenails.
Choice B reason : Shiny, thin skin on the lower extremities is more characteristic of arterial insufficiency, where there is a reduction in blood flow and oxygen to the tissues. In venous insufficiency, the skin may instead appear thickened and discolored due to stasis and buildup of hemosiderin from the breakdown of red blood cells.
Choice C reason : A dusky, red color of the feet when dangling can be a sign of dependent rubor, which is associated with arterial insufficiency. This occurs when there is a severe decrease in arterial blood flow to the lower extremities. Venous insufficiency may cause a different color change, typically a brownish discoloration due to hemosiderin deposition.
Choice D reason : Pitting edema is a hallmark sign of venous insufficiency. It occurs due to the accumulation of fluid in the tissues, which is a result of increased pressure in the veins. This pressure causes fluid to leak into the surrounding tissues, leading to swelling that retains an indentation when pressed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason : This statement is incorrect because neither heparin nor warfarin dissolves clots. They prevent the formation of new clots and the growth of existing clots.
Choice B reason : This statement is not accurate. Heparin and warfarin do not enhance each other's effects. They work in different pathways of the clotting cascade. Heparin acts quickly, whereas warfarin takes several days to reach therapeutic levels.
Choice C reason : While seeking clarification from a provider is a part of good nursing practice, it is not the most informative response for the client. The nurse should provide education based on their knowledge and available information.
Choice D reason : This is the correct response. Heparin acts quickly and is used to stabilize the patient while waiting for warfarin to reach therapeutic levels, which is monitored by the international normalized ratio (INR) and usually takes several days.
Correct Answer is A
Explanation
Choice A reason : Aspirin is well-known for its antiplatelet properties, which inhibit platelet aggregation and thus prevent the formation of new blood clots. This is particularly important following a myocardial infarction, as it helps to prevent further clotting events that could lead to additional heart attacks or strokes. Aspirin's effect on platelets is so significant that it is often one of the first medications administered in the setting of acute coronary syndrome.
Choice B reason : While aspirin does have analgesic properties, this is not the primary reason it is prescribed post-myocardial infarction. The analgesic effect of aspirin is more commonly utilized for minor pains and aches, and it is not sufficient for the pain associated with coronary artery disease.
Choice C reason : Aspirin can reduce fever, but this is not relevant to its use in coronary artery disease. Fever reduction is not a concern when prescribing aspirin for myocardial infarction patients, as the primary goal is to manage the risk of thrombosis.
Choice D reason : Aspirin does have anti-inflammatory effects, but again, this is not the primary reason for its prescription following a myocardial infarction. While inflammation plays a role in atherosclerosis and coronary artery disease, the anti-inflammatory properties of aspirin are not the main focus in the context of post-myocardial infarction treatment.
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