Which of the following assessment findings would lead the nurse to suspect the client has a venous ulcer to the right lower extremity? (SELECT ALL THAT APPLY)
irregular wound borders
distinct wound borders to plantar aspect of foot
Patient reports 9 (0-10) scale to area
minimal serous drainage
+3 edema to the mid-calf
Correct Answer : A,E
A. Venous ulcers often have irregular wound borders. This is due to the underlying venous hypertension and tissue breakdown, which can lead to irregular shapes of the ulcer.
E. Significant edema, particularly in the lower leg and ankle area (often graded as +2 or +3), is commonly associated with venous ulcers. Venous insufficiency leads to fluid accumulation in the tissues, resulting in edema.
B. This is less likely to be associated with a venous ulcer. Venous ulcers typically occur on the lower leg, particularly around the medial or lateral malleolus, rather than on the plantar aspect of the foot.
C. Severe pain, especially on a scale of 9 out of 10, is less typical of venous ulcers. Venous ulcers are usually associated with mild to moderate discomfort or pain, often described as aching or heaviness rather than severe pain.
D. Venous ulcers typically exhibit moderate to heavy serous drainage. This is due to the chronic inflammation and venous congestion that characterize venous insufficiency.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["1700"]
Explanation
To calculate the time when a new IV bag will be needed, we can divide the total volume left in the bag by the infusion rate.
With 500 ml remaining and an infusion rate of 100 ml per hour, it will take 5 hours for the current bag to be depleted.
Since the report was given at 1200 (which is noon in military time), adding 5 hours brings us to 1700, or 5:00 PM.
Therefore, the nurse should expect to hang a new IV bag at 1700 hours in military time.
Correct Answer is C
Explanation
A. Intractable pain refers to pain that is severe and persistent, difficult to control or manage despite treatment. It may be constant or intermittent but is generally not specific to a body part that has been amputated. Intractable pain is not typically used to describe pain specifically related to a phantom limb or residual limb pain after amputation.
B. Radiating pain is pain that spreads from its origin to another location in the body. It often follows the path of a nerve and can be associated with nerve compression or irritation. While radiating pain can occur in various conditions, it does not specifically describe the type of pain experienced in an amputated limb.
C. Phantom pain is perceived pain that feels like it is coming from a part of the body that has been amputated. It is a common phenomenon after limb amputation where the brain continues to receive pain signals from nerves that originally innervated the missing limb. Phantom pain is the correct term for the pain experienced by a client with a below-the-knee amputation who complains of pain in the right ankle. It is described as constant pain in the missing limb or part.
D. Referred pain is pain perceived at a location other than the site of the painful stimulus or origin. It occurs because of shared neural pathways between different areas of the body. Referred pain is not typically used to describe pain specifically related to amputation or phantom limb pain.
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