The nurse is collecting data on a patient with bilateral acute venous insufficiency. Which of the following clinical manifestations would be a priority for the nurse to report?

Bilateral edema of the legs

Bilateral hyperemia of the legs

Bilateral full superficial leg veins

Left leg cool, cyanotic skin

Answer and Explanation

The Correct Answer is D

A. Bilateral edema of the legs: While significant, bilateral edema is a common symptom of venous insufficiency and generally less urgent compared to signs of compromised circulation.
B. Bilateral hyperaemia of the legs: Hyperaemia (increased blood flow) is less concerning compared to cyanosis and coolness, which suggest severe impairment.
C. Bilateral full superficial leg veins: Prominent veins are typical in venous insufficiency and do not indicate an immediate threat.
D. Left leg cool, cyanotic skin: This is correct. Cool, cyanotic skin indicates poor perfusion and potential arterial involvement or severe venous congestion, requiring urgent assessment to prevent tissue damage.

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Correct Answer is D

Explanation

A. Place three pillows between the legs, one distal and three proximal: This is incorrect and excessive. Using three pillows in this manner can lead to improper leg positioning and discomfort.
B. Side-lying position is permitted with a pillow between the legs: While side-lying is allowed, the pillow is to prevent adduction of the legs, not just any pillow placement. It must specifically keep the hips aligned.
C. Sitting in a bedside chair is permitted if the legs are elevated: While sitting is often encouraged, elevating the legs too high can risk hip dislocation or improper alignment. The patient should sit in a way that maintains proper hip angles and alignment.
D. A triangular pillow is used between the legs to avoid adduction: A triangular or abduction pillow helps keep the legs in an appropriate position, preventing the legs from crossing and reducing the risk of hip dislocation post-surgery.

A. Greenstick B. Stress C. Avulsion D. Pathological

Correct Answer is D

Explanation

A. Greenstick: This type of fracture typically occurs in children where the bone bends and cracks, rather than breaking completely. It is not related to bone tumors.
B. Stress: Stress fractures are small cracks in the bone typically due to repetitive force or overuse, not due to underlying conditions like bone tumors.
C. Avulsion: This occurs when a fragment of bone is pulled away by a tendon or ligament due to a forceful contraction or injury, and is not typically associated with bone tumors.
D. Pathological: Pathological fractures occur in bones weakened by disease, such as bone tumors. These fractures happen with minimal or no trauma because the bone integrity is compromised by the tumor.

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