The nurse is collecting data on a patient with minor chronic venous disease. What findings are anticipated?
Purple lesions
Ankle edema
Telangiectasias
Palpable nodules
The Correct Answer is B
Choice A reason: Purple lesions could be associated with more severe venous disease or other conditions, not necessarily minor chronic venous disease.
Choice B reason: Ankle edema is a common finding in chronic venous disease due to the pooling of blood in the lower extremities.
Choice C reason: Telangiectasias, also known as spider veins, are commonly seen in chronic venous disease as they are small, visible blood vessels that can be part of the condition.
Choice D reason: Palpable nodules are not typically associated with minor chronic venous disease and could indicate other medical issues.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This response acknowledges the client's feelings without agreeing with the delusion or challenging their reality, which can help in building trust and rapport.
Choice B reason: Asking "Why do you think you are being lied about and poisoned?" could potentially reinforce the delusion and lead the client to further justify their beliefs.
Choice C reason: Directly telling the client they are mistaken can be confrontational and may damage the therapeutic relationship.
Choice D reason: Asking "Who is lying about you and trying to poison you?" can validate the delusion and is not a therapeutic response.
Correct Answer is D
Explanation
Choice A reason: Fecal impaction typically presents with the inability to pass stool and may not be associated with the absence of bowel sounds.
Choice B reason: Incisional infection is usually indicated by localized redness, warmth, and possible discharge, not necessarily by the absence of bowel sounds or flatus.
Choice C reason: Health care-associated Clostridium difficile often presents with diarrhea, not the absence of bowel sounds or flatus.
Choice D reason: Paralytic ileus is characterized by impaired intestinal motility and transit, absence of the passage of flatus, diminished bowel sounds, abdominal distension, and intestinal dilatation, fitting the symptoms described.
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