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 C
Explanation
A. Provide the client with ice chips: The client is on NPO status in preparation for surgery. Offering ice chips could increase the risk of aspiration or delay surgical procedures, so this action is not appropriate at this time.
B. Discontinue nasogastric tube: The NG tube is necessary to decompress the stomach and relieve nausea from the small-bowel obstruction. Removing it before surgery or resolution of obstruction could worsen vomiting and distention, so discontinuation is not indicated.
C. Reinforce preoperative teaching: Preoperative teaching helps reduce anxiety, improve cooperation, and prepare the client for what to expect during and after the exploratory laparotomy. This action is appropriate and supports client safety and understanding.
D. Start the prescribed antibiotic: The prescription for Cefazolin is 2 g IV and is ordered "on call for surgery." This means the antibiotic should be administered just before the surgical procedure begins, to ensure therapeutic levels are present in the bloodstream when the incision is made.
Correct Answer is C
Explanation
A. "Could you rate your pain on a scale from 0 to 10?": This question assesses the intensity of pain, not its quality. While important for pain management, it does not provide information about the type or characteristics of the pain.
B. "Do you have any pain this morning?": This question determines the presence or absence of pain, which helps identify if pain exists but does not describe its qualities or characteristics.
C. "What does your pain feel like?": Asking this allows the client to describe the quality of the pain (e.g., sharp, dull, burning, stabbing), which provides essential information for diagnosis and effective pain management.
D. "Is your pain the same as it has been?": This question compares current pain to previous experiences but does not specifically explore the nature or quality of the pain. It helps identify changes but not characteristics.
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