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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D","E"]
Explanation
Choice A reason: Monitoring cholesterol levels is essential while taking lisinopril. This medication is an angiotensin-converting enzyme (ACE) inhibitor used to treat high blood pressure, heart failure, and heart attack. Regular monitoring helps assess the impact of lisinopril on lipid levels and overall cardiovascular health. Elevated cholesterol can contribute to heart disease, so monitoring allows for timely interventions and adjustments in treatment.
Choice C reason: Potassium-rich foods are relevant because lisinopril can affect potassium levels. ACE inhibitors may lead to hyperkalemia (high potassium levels), especially in patients with impaired kidney function. Encouraging potassium-rich foods helps maintain a balance and prevent complications.
Choice D reason: Reporting a persistent dry cough is crucial. Lisinopril is associated with a common side effect: a dry, persistent cough. This occurs due to increased levels of bradykinin, a substance affected by ACE inhibitors. If the client experiences this cough, it's essential to notify the doctor for potential medication adjustments.
Choice E reason: Monitoring blood pressure aligns with the purpose of lisinopril. Regular blood pressure checks help assess the effectiveness of the medication in controlling hypertension. Consistent monitoring ensures timely adjustments and prevents complications related to high blood pressure.
Correct Answer is B
Explanation
Choice A reason : S1 represents the sound made by the closure of the atrioventricular valves (mitral and tricuspid valves) and is not the sound associated with the closure of the aortic and pulmonic valves.
Choice B reason : S2 is the sound heard when the aortic and pulmonic valves close. It is often described as a "dub" and occurs at the end of ventricular systole.
Choice C reason : S3 is a rare extra heart sound that follows S2 and usually indicates an increase in left ventricular filling pressure, which can be found in conditions such as heart failure.
Choice D reason : S4 is another extra heart sound that occurs just before S1. It is typically associated with a stiff or hypertrophic ventricle and is not related to the closure of the aortic and pulmonic valves
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