The nurse is caring for a patient who has a venous leg ulcer. The patient asks why these ulcers occur. What will the nurse explain as the cause for the development of venous ulcers?
"Your veins are not functioning properly. Lack of venous blood volume causes these ulcers"
"Your veins are weaker and blood is not moving up as it should. The congestion in your veins causes the ulcers to form.
"Because the veins are not working properly, there is not enough oxygen going to the skin of your legs."
"Your veins clogged so the body causes the arteries to swell and the excess oxygen in the blood causes the ulcers."
The Correct Answer is B
A. "Your veins are not functioning properly. Lack of venous blood volume causes these ulcers": While venous insufficiency contributes to the development of venous ulcers, the primary issue is not necessarily a lack of venous blood volume but rather impaired venous return due to valve dysfunction.
B. "Your veins are weaker and blood is not moving up as it should. The congestion in your veins causes the ulcers to form.": This explanation accurately describes the pathophysiology of venous ulcers. Venous insufficiency leads to venous congestion, which causes increased pressure in the veins of the lower extremities. This pressure can result in the breakdown of skin and the formation of ulcers, typically around the ankles.
C. "Because the veins are not working properly, there is not enough oxygen going to the skin of your legs.": While venous insufficiency can affect tissue oxygenation to some extent, the primary mechanism leading to venous ulcers is venous congestion and increased pressure in the lower extremities, rather than insufficient oxygen delivery.
D. "Your veins clogged so the body causes the arteries to swell and the excess oxygen in the blood causes the ulcers.": This explanation does not accurately describe the pathophysiology of venous ulcers. Venous ulcers result from impaired venous return and venous congestion, not arterial swelling or excess oxygen in the blood.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Let your provider know if a new cough occurs:
This teaching is essential because lisinopril, an angiotensin-converting enzyme (ACE) inhibitor, is associated with a potential side effect of a persistent, dry cough. Notifying the healthcare provider if a new cough develops allows for appropriate management, such as discontinuation or adjustment of the medication to alleviate the symptom.
B. Take the medication on a full stomach:
Taking lisinopril with or without food is acceptable, as it does not significantly affect its absorption. However, taking it on an empty stomach is often recommended to optimize absorption. Advising the patient to take the medication on a full stomach is incorrect and may lead to misunderstandings.
C. This medication will not cause edema:
Lisinopril, as an ACE inhibitor, may actually cause or exacerbate edema as a side effect. It can lead to vasodilation and fluid retention, particularly in susceptible individuals. Providing incorrect information about the medication's potential side effects can compromise patient understanding and safety.
D. Eat a high potassium diet:
Lisinopril can increase serum potassium levels, so instructing the patient to consume a high-potassium diet may exacerbate this effect and lead to hyperkalemia. While dietary potassium intake should be monitored, advising a high-potassium diet without proper guidance can pose risks to the patient's health.
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.
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