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 B

Explanation

A. Have the patient lie in bed with a pillow under the knees: Elevation of the legs can reduce blood flow to the feet, worsening symptoms. Additionally, putting a pillow under the knees can compress arteries further, exacerbating ischemia.
B. Evaluate the distal pulses: Assessing the distal pulses is crucial for determining the severity of blood flow impairment and helps in understanding the extent of peripheral arterial disease.
C. Cover the patient with a blanket: While warmth might provide some comfort, it does not address the underlying vascular issue and is not a primary intervention for this condition.
D. Notify the physician: While it may be necessary eventually, evaluating the patient's distal pulses first will provide critical information that the nurse can report to the physician.

A. TIA B. Stroke C. CVA D. OSAH

Correct Answer is A

Explanation

A. TIA: A transient ischemic attack (TIA) is characterized by temporary symptoms due to a brief period of reduced blood flow to the brain, with no lasting damage.
B. Stroke: A stroke involves a more prolonged interruption of blood flow to the brain and typically results in permanent neurological damage.
C. CVA: Cerebrovascular accident (CVA) is another term for stroke, involving sustained damage.
D. OSAH: This is not a relevant term or acronym for the condition described. It is not related to cerebral circulation impairment.

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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?

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