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 : Guided imagery is a relaxation technique that can help reduce stress and anxiety, but it does not directly address the physiological issues of dehydration and hypotension. While it may be beneficial as a complementary therapy, it is not the primary intervention for a patient suffering from these conditions.

Choice B reason : Elevating the head of the bed is generally recommended for patients who have difficulty breathing or to prevent aspiration, but it is not the standard care for hypotension. In fact, for a hypotensive patient, elevating the legs might be more beneficial to promote venous return to the heart⁹[^20^].

Choice C reason : Increasing fluid intake is the most direct and effective way to treat dehydration. When a patient is hypotensive, it often indicates a low blood volume, which can be improved by increasing fluid intake. This can be done orally if the patient is conscious and able to drink, or intravenously if they are not. The normal range for blood pressure is 90/60 mmHg to 120/80 mmHg, and maintaining adequate hydration helps to ensure blood pressure stays within this range⁸.

Choice D reason : The Valsalva maneuver is a technique used to potentially correct certain types of abnormal heart rhythms, particularly supraventricular tachycardia, and not for treating hypotension or dehydration. It involves increasing intrathoracic pressure by exhaling forcefully with a closed airway, which can have various effects on the cardiovascular system. However, it is not an appropriate intervention for a dehydrated, hypotensive patient⁹[^10^].

A. "I will not go barefoot." B. "I will use a thermometer to check the temperature of my bath water." C. "I will wear stockings with elastic tops." D. "I will avoid crossing my legs at the knees."

Correct Answer is C

Explanation

Choice A reason : Advising a client with PVD not to go barefoot is correct. Going barefoot can increase the risk of injury to the feet, which can be particularly dangerous in individuals with PVD due to poor circulation. Any injuries to the feet may heal poorly and can lead to complications such as ulcers or infections.

Choice B reason : Using a thermometer to check the temperature of bath water is a recommended practice for clients with PVD. Due to potential nerve damage and reduced sensation in the extremities, clients may not accurately gauge water temperature, leading to burns. Therefore, using a thermometer helps prevent thermal injury.

Choice C reason : Wearing stockings with elastic tops is not recommended for clients with PVD. Elastic tops can constrict blood flow in the legs, exacerbating circulation problems. Instead, clients should wear non-constricting, well-fitting socks or stockings that promote blood flow.

Choice D reason : Avoiding crossing legs at the knees is good advice for clients with PVD. Crossing the legs can restrict blood flow to the lower extremities, which is already compromised in PVD. Keeping the legs uncrossed and elevating them when possible can help improve circulation.

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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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