The nurse is assessing a patient diagnosed with chronic venous insufficiency. Which clinical manifestations are consistent with this diagnosis? Select All That Apply
Superficial ulcers in the calves
Dilatation of superficial veins
Shiny skin
Blackened toes
Dependent rubor
Correct Answer : A,B,C,E
A. Superficial ulcers in the calves: Chronic venous insufficiency can lead to poor circulation in the lower legs, causing tissue damage and the development of superficial ulcers, typically located around the ankles or calves.
B. Dilatation of superficial veins: One of the hallmark signs of chronic venous insufficiency is the visible dilatation (enlargement) of superficial veins, often seen as varicose veins, due to the impaired return of blood to the heart.
C. Shiny skin: Chronic venous insufficiency can cause changes in the skin texture, including thinning and a shiny appearance. This occurs due to chronic edema and impaired circulation in the affected area.
D. Blackened toes: Blackened toes are not typically associated with chronic venous insufficiency. This symptom is more commonly seen in conditions such as peripheral artery disease (PAD) or severe ischemia.
E. Dependent rubor: Dependent rubor, characterized by reddish-blue discoloration of the lower extremities when in a dependent position (e.g., hanging off the bed), can occur in chronic venous insufficiency due to impaired venous return and pooling of blood in the lower extremities.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Encourage the patient and family to manage the patient's activity level and activities of daily living effectively: While managing activity levels and daily living tasks is important for overall health and well-being, this action alone may not directly address feelings of isolation experienced by the patient. Encouraging social support and addressing emotional needs are also vital aspects of care for someone with HIV.
B. Encourage the patient to express feelings of isolation and loneliness, with the assurance that these feelings are not unique or abnormal: Patients with HIV often experience feelings of isolation and loneliness due to stigma, fear of rejection, or loss of social support. Encouraging the patient to openly express these feelings can help them feel validated and understood. Assuring them that such feelings are common among individuals with HIV can help reduce their sense of isolation and promote emotional well-being.
C. Encourage the patient and family to be active partners in the management of immunodeficiency: While involving the patient and family in the management of HIV is essential, this action primarily focuses on medical management rather than addressing the psychosocial aspect of isolation. Collaborative care is important, but addressing emotional needs should also be prioritized.
D. Make sure that the patient and family know how to adjust dosages of the medications used in treatment: While medication adherence is crucial in managing HIV, ensuring proper dosage adjustments is primarily a clinical aspect of care. While important, this action alone may not directly address the patient's feelings of isolation.
Correct Answer is D
Explanation
Answer: D
Rationale:
A) A renal ultrasound: A renal ultrasound is not typically used to confirm a diagnosis of hypertension. While renal artery stenosis can contribute to hypertension in some cases, it is not the primary diagnostic test for hypertension.
B) A cardiac stress test: A cardiac stress test is not used to confirm a diagnosis of hypertension. It is primarily used to assess cardiovascular function and detect coronary artery disease or cardiac arrhythmias.
C) A manual blood pressure cuff: While manual blood pressure measurements can provide accurate readings, they are subject to potential inaccuracies due to factors such as observer bias and white coat syndrome. Therefore, they may not be the most reliable method for confirming a diagnosis of hypertension.
D) Ambulatory blood pressure measurement: Ambulatory blood pressure measurement involves obtaining multiple blood pressure readings over a 24-hour period using a portable monitor. It is considered the gold standard for diagnosing hypertension, as it provides a more comprehensive assessment of blood pressure variability and reduces the impact of white coat syndrome. Therefore, it is the preferred diagnostic test in this scenario to confirm whether the patient has hypertension outside of the clinical setting.
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