A nurse is checking the skin of a client who has chronic venous insufficiency. Which of the following images should the nurse identify as a venous stasis ulcer?
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A
B
The Correct Answer is B
A. The top image shows a raised, erythematous plaque with silvery scaling (most likely a plaque of psoriasis or other dermatitis), which is a common skin lesion but is not characteristic of a venous stasis ulcer, which is a depressed, often shallow, open wound.
B. The bottom image displays a client's lower legs with prominent, dilated veins (varicose veins) and associated hyperpigmentation (darkening of the skin) and edema (swelling). These findings are the hallmark signs of chronic venous insufficiency and stasis dermatitis, the underlying condition that directly causes venous stasis ulcers.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Reduce intake of whole grains: Whole grains contain fiber, antioxidants, and phytonutrients that help lower cancer risk by supporting healthy digestion and reducing inflammation. Limiting them removes protective nutrients that assist in regulating cell growth. Reduced whole-grain intake is not recommended in cancer-prevention guidelines.
B. Increase intake of saturated fats: Saturated fats are associated with inflammation, obesity, and cardiovascular strain, all of which can raise overall cancer risk. Higher intake contributes to hormone-related cancers and metabolic stress. Dietary guidelines consistently encourage limiting, not increasing, saturated fats.
C. Reduce intake of legumes: Legumes supply fiber, plant protein, and micronutrients that support colon health and reduce carcinogenic processes in the bowel. They help stabilize blood glucose and decrease inflammatory responses. Reducing them removes valuable cancer-protective dietary components.
D. Increase intake of fatty fish: Fatty fish contain omega-3 fatty acids that reduce inflammation, support cellular health, and may inhibit tumor growth. Regular intake is associated with lower risk of several cancers, including colorectal and breast cancer. Including fatty fish aligns with major cancer-prevention nutritional guidelines.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A"}}
Explanation
• Place the client on NPO status: Clients with compartment syndrome often require emergent surgical intervention, such as a fasciotomy. Keeping the client NPO ensures safety in case anesthesia is needed for immediate surgery.
• Obtain a urinalysis: Compartment syndrome can lead to rhabdomyolysis and myoglobinuria, which can damage the kidneys. A urinalysis helps detect myoglobin in the urine and guides interventions to prevent acute kidney injury.
• Place the client's right leg in a dependent position: Lowering the affected limb increases pressure within the compartment, worsening ischemia and tissue damage. The limb should be kept at heart level or slightly elevated to optimize perfusion without increasing pressure.
• Open the splint: Removing the splint or cast without surgical or provider guidance can worsen tissue swelling and damage, as well as increase the risk of further injury. Immediate provider assessment is required before altering immobilization.
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