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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Echinacea enhances immune function but has minimal effects on coagulation. It is not commonly associated with adverse interactions with anticoagulants like enoxaparin unless paired with other supplements causing significant immune changes.
Choice B rationale
Ginkgo biloba poses an increased bleeding risk due to antiplatelet effects, which can compound the anticoagulant properties of enoxaparin. This interaction necessitates close monitoring and communication with the provider.
Choice C rationale
Probiotics aid gastrointestinal health without influencing coagulation pathways or interacting significantly with anticoagulants. They are generally safe to continue unless contraindicated by other clinical factors.
Choice D rationale
Flaxseed powder contains omega-3 fatty acids, which may have mild anticoagulant properties. However, this interaction is usually not clinically significant unless used in large quantities alongside other anticoagulants. .
Correct Answer is B
Explanation
Choice A rationale
CD4 T-cell count evaluates immune function, not nutritional intake. Nutritional deficiencies do not directly affect CD4 T-cell counts unless severe malnutrition impacts immune function over time.
Choice B rationale
Albumin is a protein produced by the liver that reflects long-term nutritional status. Normal albumin levels (3.5-5.0 g/dL) indicate adequate protein intake and nutritional sufficiency. Low levels suggest malnutrition or protein deficiency.
Choice C rationale
Lipase is an enzyme involved in fat digestion and does not reflect overall nutritional status. Monitoring lipase levels is specific to pancreatic function or disorders rather than nutritional intake.
Choice D rationale
Creatinine clearance measures kidney function and is not an indicator of nutritional adequacy. It evaluates renal filtration and is influenced by muscle mass rather than nutritional intake.
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