A 68-year-old woman is scheduled to undergo mitral valve replacement for severe mitral stenosis and mitral regurgitation. Although the diagnosis was made during childhood, she did not have any symptoms until 4 years ago. Recently, she noticed increased symptoms, despite daily doses of digoxin and furosemide. During the initial interview with the nice lady, the nurse would most likely learn that the client’s childhood health history included:
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Solution
Rheumatic fever
Most clients with mitral stenosis have a history of rheumatic fever or bacterial endocarditis.
A nurse is caring for a client who had a percutaneous insertion of an inferior vena cava filter and was on heparin therapy before surgery. The nurse would inspect the surgical site most closely for signs of:
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Solution
Bleeding and infection
After inferior vena cava insertion, the nurse inspects the surgical site for bleeding and signs and symptoms of infection. Otherwise, care is the same as for any post-op client.
A nurse is assessing a client with an abdominal aortic aneurysm. Which of the following assessment findings by the nurse is probably unrelated to an aneurysm?
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Solution
Hyperactive bowel sounds in that area
Not all clients with abdominal aortic aneurysms exhibit symptoms.
Option A: A pulsatile mass may be palpated in the middle and upper abdomen.
Option C: A systolic bruit may be auscultated over the mass. Hyperactive bowel sounds are not related specifically to an abdominal aortic aneurysm.
Option D: Those who do describe a feeling of the “heart beating” in the abdomen when supine or be able to feel the mass throbbing.
Which technique is considered the gold standard for diagnosing DVT?
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Solution
Venography
Varicose veins can cause changes in what component of Virchow’s triad?
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Solution
Blood flow
Cancer can cause changes in what component of Virchow’s triad?
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Solution
Blood coagulability
Which of the following characteristics is typical of the pain associated with DVT?
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Solution
Sudden onset
DVT is associated with deep leg pain of sudden onset, which occurs secondary to the occlusion.
Option A: A dull ache is more commonly associated with varicose veins.
Option C: If the thrombus is large enough, it will cause pain.
Option D: A tingling sensation is associated with an alteration in arterial blood flow.
A client comes to the outpatient clinic and tells the nurse that he has had legs pains that began when he walks but cease when he stops walking. Which of the following conditions would the nurse assess for?
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Solution
Peripheral vascular problems in both legs
Intermittent claudication is a condition that indicates vascular deficiencies in the peripheral vascular system.
Option A: If an obstruction were present, the leg pain would persist when the client stops walking.
Option D: Low calcium levels may cause leg cramps but would not necessarily be related to walking.
In preparation for the discharge of a client with arterial insufficiency and Raynaud’s disease, client teaching instructions should include:
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Solution
Keeping the heat up so that the environment is warm
The client’s instructions should include keeping the environment warm to prevent vasoconstriction.
Option A: Walking would most likely increase pain.
Option C: Wearing gloves, warm clothes, and socks will also be useful when preventing vasoconstriction, but TED hose would not be therapeutic.
A client is admitted with a venous stasis leg ulcer. A nurse assesses the ulcer, expecting to note that the ulcer:
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Solution
Has brown pigmentation around it.
Venous leg ulcers, also called stasis ulcers, tend to be more superficial than arterial ulcers, and the ulcer bed is pink. The edges of the ulcer are uneven, and granulation tissue is evident. The skin has a brown pigmentation from the accumulation of metabolic waste products resulting from venous stasis. The client also exhibits peripheral edema.
Options A, B, and C is due to tissue malnutrition; and thus us an arterial problem)
A nurse is assessing the neurovascular status of a client who returned to the surgical nursing unit 4 hours ago after undergoing aortoiliac bypass graft. The affected leg is warm, and the nurse notes redness and edema. The pedal pulse is palpable and unchanged from admission. The nurse interprets that the neurovascular status is:
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Solution
Normal because of the increased blood flow through the leg
An expected outcome of surgery is warmth, redness, and edema in the surgical extremity because of increased blood flow.