A nurse is collecting data from a client who has venous insufficiency. Which of the following findings should the nurse expect?

Thickened toenails

Shiny, thin skin on the lower extremities

Dusky, red color of the feet when dangling

Pitting edema

Answer and Explanation

The Correct Answer is D

Choice A reason : Thickened toenails are often associated with fungal infections and are not a direct symptom of venous insufficiency. However, they can appear in patients with chronic venous insufficiency due to poor circulation that affects the health of the toenails.

Choice B reason : Shiny, thin skin on the lower extremities is more characteristic of arterial insufficiency, where there is a reduction in blood flow and oxygen to the tissues. In venous insufficiency, the skin may instead appear thickened and discolored due to stasis and buildup of hemosiderin from the breakdown of red blood cells.

Choice C reason : A dusky, red color of the feet when dangling can be a sign of dependent rubor, which is associated with arterial insufficiency. This occurs when there is a severe decrease in arterial blood flow to the lower extremities. Venous insufficiency may cause a different color change, typically a brownish discoloration due to hemosiderin deposition.

Choice D reason : Pitting edema is a hallmark sign of venous insufficiency. It occurs due to the accumulation of fluid in the tissues, which is a result of increased pressure in the veins. This pressure causes fluid to leak into the surrounding tissues, leading to swelling that retains an indentation when pressed.

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Correct Answer is C

Explanation

Choice A reason : Setting a goal body weight within 25% of the ideal body weight can be misleading. The ideal body weight should be determined based on body mass index (BMI), considering the individual's height and weight. A BMI of 18.5 to 24.9 is considered normal.

Choice B reason : This is a general guideline for alcohol consumption, but for individuals with hypertension, it is often recommended to limit alcohol intake even further to help manage blood pressure

Choice C reason : This is a key recommendation for managing hypertension. Reducing sodium intake helps lower blood pressure and is a widely accepted guideline

Choice D reason : Monitoring potassium levels is crucial when taking thiazide diuretics because these medications can decrease potassium levels in the blood, leading to hypokalemia.

A. Dyspnea B. Jugular vein distention C. Orthopnea D. Crackles

Correct Answer is ["A","C","D"]

Explanation

Choice A reason : Dyspnea, or difficulty breathing, is a common symptom of left-sided heart failure. It occurs because the heart is unable to pump efficiently, leading to a backup of fluid in the lungs, which can cause shortness of breath.

Choice B reason : Jugular vein distention is typically associated with right-sided heart failure, not left-sided. It occurs when there is an increased pressure in the right atrium, leading to visible bulging of the neck veins.

Choice C reason : Orthopnea, or difficulty breathing while lying flat, is another symptom of left-sided heart failure. Fluid accumulation in the lungs makes it difficult for the patient to breathe without elevation, hence they may need to sleep with extra pillows.

Choice D reason : Crackles, which are heard during lung auscultation, are indicative of fluid accumulation in the alveoli due to the inefficiency of the left side of the heart to pump blood, leading to pulmonary congestion.

Choice E reason : Tachycardia, or rapid heartbeat, can be a response to left-sided heart failure as the body attempts to compensate for the decreased cardiac output by increasing the heart rate to maintain adequate blood flow.

Choice F reason : Gastrointestinal bloating is more commonly associated with right-sided heart failure due to systemic venous congestion leading to fluid accumulation in the abdominal organs and tissues.

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A nurse is collecting data from a client who has venous insufficiency. Which of the following findings should the nurse expect?

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