A nurse is checking the skin of a client who has chronic venous insufficiency.
Which of the following findings should the nurse identify as a venous stasis ulcer?

Red scaly patches with raised edges.

Round lesions with irregular borders.

Wounds with darkened pigmentation and drainage.

Circular areas with pale centers.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Red scaly patches with raised edges are characteristic of skin conditions like psoriasis or eczema, not venous stasis ulcers, which result from chronic venous insufficiency.

Choice B rationale

Round lesions with irregular borders are commonly seen in arterial ulcers. They result from ischemia rather than chronic venous insufficiency and differ in appearance from venous stasis ulcers.

Choice C rationale

Wounds with darkened pigmentation and drainage are hallmarks of venous stasis ulcers. Chronic venous insufficiency causes venous hypertension, leading to hemosiderin deposition, pigmentation, and wound development.

Choice D rationale

Circular areas with pale centers are associated with conditions like erythema multiforme or arterial issues, not with venous stasis ulcers arising from venous insufficiency.

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Correct Answer is C

Explanation

Choice A rationale

Palm oil is high in saturated fats, which increase LDL cholesterol levels and promote atherosclerosis progression, making it unsuitable for lowering fat and cholesterol.

Choice B rationale

Increasing consumption of 2% milk elevates intake of saturated fats, which can raise LDL cholesterol levels, negating dietary goals for atherosclerosis management.

Choice C rationale

Limiting meat portions to 3 ounces per meal controls saturated fat intake, reducing LDL cholesterol levels. It aligns with dietary recommendations for managing atherosclerosis.

Choice D rationale

Baked goods containing trans fats increase LDL cholesterol while decreasing HDL cholesterol levels, worsening atherosclerosis risk and contradicting dietary teaching. .

A. There is 20 mL of dark red drainage from the wound drainage device over the past 4 hours. B. The client reports a pain level of 6 on a scale from 1 to 10 at the incision site. C. There is 60 mL of dark yellow urine from the indwelling urinary catheter over the past 4 hours. D. The client arouses easily but quickly falls back asleep.

Correct Answer is D

Explanation

Choice A rationale

A small amount of dark red wound drainage, such as 20 mL over 4 hours, is a typical postoperative finding in clients following bowel surgery. This observation indicates normal postoperative healing and does not require immediate intervention, making it a lower priority.

Choice B rationale

Pain at the incision site rated as 6 out of 10 is a moderate pain level that is expected in the postoperative period. While managing pain is important, this is not an urgent priority compared to other clinical findings that indicate systemic compromise or potential complications.

Choice C rationale

Dark yellow urine output totaling 60 mL over 4 hours reflects low urine output but does not meet the oliguria threshold of less than 30 mL per hour. This finding may require further assessment but is not immediately critical compared to symptoms of altered consciousness.

Choice D rationale

A client arousing easily but quickly falling back asleep indicates a potential alteration in consciousness, which can result from hypovolemia, hypoxia, or other complications. This finding is a priority for reporting as it may signify deteriorating neurological or hemodynamic status that requires immediate intervention. .

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A nurse is checking the skin of a client who has chronic venous insufficiency.Which of the following findings should the nurse identify as a venous stasis ulcer?

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A nurse is checking the skin of a client who has chronic venous insufficiency.
Which of the following findings should the nurse identify as a venous stasis ulcer?