A nurse is planning care for a client who has peripheral venous disease. Which of the following interventions should the nurse include in the plan of care? (Select All that Apply.)

Intermittent pneumatic compression pumps

Ankle-brachial index test

Layered wraps

Elevation of legs

Exercise

Answer and Explanation

Correct Answer : A,C,D,E

A. Intermittent pneumatic compression pumps: Intermittent pneumatic compression pumps can help improve circulation in the lower extremities by assisting with venous return. These devices inflate and deflate sequentially, promoting venous blood flow and reducing edema in clients with peripheral venous disease.

B. Ankle-brachial index test: The ankle-brachial index (ABI) test is a non-invasive vascular study used to assess peripheral arterial disease (PAD). It compares the blood pressure in the ankle with the blood pressure in the arm to evaluate arterial circulation.

C. Layered wraps: Layered wraps, such as compression bandages or stockings, are typically used in the management of venous insufficiency and venous ulcers. They are not as commonly utilized in peripheral venous disease, however, they may be beneficial for some clients with PVD.

D. Elevation of legs: Elevating the legs above the level of the heart can help reduce edema and improve venous return in clients with peripheral venous disease. Gravity assists in draining blood from the lower extremities back toward the heart, thereby reducing swelling and discomfort.

E. Exercise: Regular physical activity, particularly lower extremity exercises such as walking, can promote venous return and improve circulation in clients with peripheral venous disease. Exercise helps to pump blood back to the heart, reducing venous stasis and the risk of complications such as venous thrombosis.

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Correct Answer is ["C","D","E"]

Explanation

A. Respiratory rate of 12/min: A respiratory rate of 12/min is within the normal adult range (12-20 breaths per minute). In the context of increased intracranial pressure (ICP), respiratory rate changes might be noted as part of the Cushing's reflex (which is characterized by bradycardia, hypertension, and abnormal respiratory patterns like Cheyne-Stokes or ataxic breathing), but a rate of 12/min on its own is not indicative of a worsening condition. However, if the patient begins to show signs of irregular or abnormal breathing patterns, this would raise concern.

B. Blood pressure of 108/74 mm Hg: This blood pressure is also within the normal range and does not suggest a worsening of intracranial pressure. In fact, ICP can lead to a rise in blood pressure (due to the body's compensatory mechanisms, known as Cushing's triad), along with bradycardia and abnormal respirations. Thus, a stable blood pressure like 108/74 mm Hg is not concerning in this context.

C. Changes to pupil size and shape: Changes in pupil size, shape, or reactivity are significant indicators of worsening intracranial pressure. Unequal pupils (anisocoria), sluggish or absent response to light, and fixed dilated pupils are signs of brainstem compression or damage, which often occur as ICP increases. This could indicate herniation or severe brain injury, which are worsening conditions.

D. Swelling of the optic nerve: Swelling of the optic nerve, or papilledema, is another important sign of increased intracranial pressure. It occurs due to increased pressure within the skull, which causes congestion and swelling of the optic disc. This finding can be seen on fundoscopy and indicates a worsening condition, as it suggests elevated pressure affecting the brain.

E. Decreasing Glasgow Coma scores: A decreasing Glasgow Coma Scale (GCS) score is a critical indicator of worsening neurologic function in a patient with increased ICP. The GCS is used to assess a patient's level of consciousness, and a decreasing score suggests that the brain's function is deteriorating. This can be caused by worsening edema, brain herniation, or other severe neurological impairments associated with elevated ICP.

A. Diabetes mellitus B. Total cholesterol 170 mg/dL (less than 200 mg /Dl C. HDL cholesterol 65 mg/dL (male greater than 45 mg/dL; female greater than 55 mg/dL) D. Smoking cigarettes E. Family history of aneurysm

Correct Answer is ["D","E"]

Explanation

A. Diabetes mellitus: An inverse association between diabetes mellitus (DM) and abdominal aortic aneurysm (AAA) risk hasbeen reported. Apart from a lower AAA prevalence among patients with vsthose without DM, there isdata showing that DM may exert a protective role on aneurysmal growth in patients with small AAAs, thus decreasing the risk of rupture. As atherosclerosis has almost the same risk factors as aneurysms, the decreased AAA prevalence in patients with DM may indicate that atherosclerosis is an associated feature and not a cause of the aneurysms.

B. Total cholesterol 170 mg/dL (less than 200 mg/dL): While elevated total cholesterol is a risk factor for cardiovascular disease, it is not specifically listed as a risk factor for abdominal aortic aneurysm (AAA). However, dyslipidemia, including elevated total cholesterol levels, can contribute to the development of atherosclerosis, which is a risk factor for AAA.

C. HDL cholesterol 65 mg/dL (male greater than 45 mg/dL; female greater than 55 mg/dL): High-density lipoprotein (HDL) cholesterol levels greater than 65 mg/dL are not listed as a risk factor for abdominal aortic aneurysm (AAA). However, low levels of HDL cholesterol are associated with an increased risk of cardiovascular disease, which may indirectly contribute to the development of AAA through the promotion of atherosclerosis.

D. Smoking cigarettes: Smoking cigarettes is a significant modifiable risk factor for abdominal aortic aneurysm (AAA). Smoking damages the walls of blood vessels, promotes inflammation, and accelerates the development of atherosclerosis, increasing the risk of AAA formation and rupture.

E. Family history of aneurysm: A family history of aneurysm, particularly abdominal aortic aneurysm (AAA), is a risk factor for developing AAA. Genetic factors can predispose individuals to the development of aneurysms, and a positive family history increases the likelihood of AAA occurrence.

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A nurse is planning care for a client who has peripheral venous disease. Which of the following interventions should the nurse include in the plan of care? (Select All that Apply.)

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has increased intracranial pressure and has a worsening neurologic condition. Which of the following cues should the nurse recognize as a worsening condition? (Select All that Apply.)

Correct Answer is ["C","D","E"]

Explanation

Which of the following are risk factors for abdominal aortic aneurysm (AAA)? (Select all that apply.)

Correct Answer is ["D","E"]

Explanation

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