A nurse is assessing a client who has chronic venous insufficiency. Which of the following findings should the nurse expect?
Thick, deformed toenails
Edema
Dependent rubor
Hair loss
The Correct Answer is B
Edema is a common finding in clients who have chronic venous insufficiency, due to the impaired venous return and increased capillary pressure. The edema is usually worse at the end of the day and improves with elevation.
a. Thick, deformed toenails are more likely to be seen in clients who have fungal infections or peripheral arterial disease, not chronic venous insufficiency.
c. Dependent rubor is a sign of peripheral arterial disease, not chronic venous insufficiency. It is a reddish color of the lower extremities that occurs when they are lowered and disappears when they are elevated.
d. Hair loss is another sign of peripheral arterial disease, not chronic venous insufficiency. It is caused by the reduced blood supply to the hair follicles.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The priority nursing action is to notify the provider of the client's allergy because shellfish allergy may indicate an allergy to iodine, which is commonly used as a contrast dye in cardiac catheterization. This could cause a severe allergic reaction or anaphylaxis during the procedure, which could be life-threatening. The provider may need to order a different type of contrast dye or premedicate the client with antihistamines or steroids to prevent an allergic reaction.
a. Ask the client if any other foods cause such a reaction is wrong because it is not the priority action and it does not address the potential risk of iodine allergy.
c. Notify the dietary department of the client's allergy is wrong because it is not relevant to the cardiac catheterization and it does not prevent an allergic reaction during the procedure.
d. Atach a wrist band indicating the client's allergy is wrong because it is not sufficient to alert the provider or the catheterization team of the client's allergy and it does not prevent an allergic reaction during the procedure.
Correct Answer is C
Explanation
Placing the client on his side is an essential action to take during a seizure, as it can prevent airway obstruction and aspiration. The client should be placed on his side, preferably in a lateral recumbent position, to allow saliva and secretions to drain from the mouth.
Holding the client's arms and legs from moving is not appropriate, as it can cause injury, increase agitation, or prolong the seizure. The client should be allowed to move freely during a seizure, but supported and guided away from hazards.
Placing the client back in bed is not necessary, as it can cause harm or delay care. The client should be left on the floor, unless it is unsafe or uncomfortable, and padded with pillows or blankets to protect from injury.
Inserting a tongue blade in the client's mouth is not advisable, as it can cause oral trauma, choking, or damage to the teeth. The client should not have anything inserted into his mouth during a seizure, as he cannot swallow or bite his tongue. The nurse should ensure that the client's airway is clear and patent.
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