A nurse is providing care for a client diagnosed with diabetic ketoacidosis (DK
Exercise
Elevation of legs
Intermittent pneumatic compression pumps
Ankle-brachial index test
Layered wraps
Correct Answer : A,B,C,E
Choice A reason: Exercise
Exercise is a crucial component in the management of peripheral venous disease (PVD). Regular physical activity helps improve blood circulation and reduces symptoms such as pain and swelling. Walking, in particular, is highly recommended as it promotes venous return and enhances overall cardiovascular health. Exercise also helps in weight management, which can alleviate the pressure on the veins and improve symptoms of PVD.
Choice B reason: Elevation of Legs
Elevating the legs is a simple yet effective way to reduce swelling and improve blood flow in patients with PVD1. By raising the legs above the level of the heart, gravity helps to reduce the pooling of blood in the lower extremities, thereby decreasing edema and discomfort. This practice is especially beneficial when done regularly, such as during rest periods or while sleeping.
Choice C reason: Intermittent Pneumatic Compression Pumps
Intermittent pneumatic compression (IPC) pumps are devices used to enhance blood flow in the legs. These devices consist of inflatable sleeves that wrap around the legs and periodically inflate and deflate, mimicking the natural muscle contractions that help push blood back toward the heart. IPC pumps are particularly useful for patients who are immobile or have difficulty engaging in physical activity, as they help prevent blood clots and reduce swelling.
Choice D reason: Ankle-Brachial Index Test
The ankle-brachial index (ABI) test is a diagnostic tool used to assess the severity of peripheral artery disease (PAD), not peripheral venous disease. The test compares the blood pressure in the ankle with the blood pressure in the arm to determine the presence of arterial blockages. While the ABI test is important for diagnosing PAD, it is not a treatment or management strategy for PVD. Therefore, it is not included in the plan of care for PVD.
Choice E reason: Layered Wraps
Layered wraps, also known as compression bandages, are used to manage symptoms of PVD by providing consistent pressure to the legs. These wraps help reduce swelling, improve venous return, and prevent the formation of ulcers. Compression therapy is a cornerstone in the management of chronic venous insufficiency and related conditions, making layered wraps an essential part of the care plan for patients with PVD.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason:
A serum potassium level of 5.0 mEq/L is within the normal range (3.5-5.0 mEq/L). While it is on the higher end of normal, it does not require immediate intervention in the context of SIADH. Potassium levels are crucial for cardiac and muscle function, but this value does not indicate a critical imbalance.
Choice B reason:
A serum calcium level of 8.0 mg/dL is slightly below the normal range (8.5-10.2 mg/dL). Mild hypocalcemia can occur in various conditions, but it is not typically associated with SIADH and does not require immediate intervention unless symptomatic or significantly lower.
Choice C reason:
A serum sodium level of 125 mEq/L indicates hyponatremia, which is a hallmark of SIADH. Hyponatremia can lead to severe neurological symptoms, including seizures, confusion, and coma, especially if it develops rapidly. Immediate intervention is required to correct the sodium imbalance and prevent serious complications.
Choice D reason:
A blood urea nitrogen (BUN) level of 24 mg/dL is within the upper normal range (7-20 mg/dL). While slightly elevated, it is not critically high and does not require immediate intervention in the context of SIADH. BUN levels can be influenced by various factors, including hydration status and renal function.
Correct Answer is B
Explanation
Choice A reason: Increased Thirst, Increased Urine Output, and Weight Loss
Increased thirst, increased urine output, and weight loss are symptoms commonly associated with diabetes mellitus, particularly uncontrolled diabetes. These symptoms occur due to the body’s attempt to eliminate excess glucose through urine, leading to dehydration and subsequent weight loss. However, these symptoms are not typically associated with elevated TSH levels, which indicate hypothyroidism.
Choice B reason: Fatigue, Constipation, Weight Gain
Fatigue, constipation, and weight gain are classic symptoms of hypothyroidism2. When the thyroid gland is underactive, it produces insufficient thyroid hormones, leading to a slowdown in the body’s metabolism. This results in fatigue, weight gain, and constipation, among other symptoms. Elevated TSH levels are a compensatory response by the pituitary gland to stimulate the thyroid to produce more hormones, confirming hypothyroidism.
Choice C reason: Anxiety, Unintended Weight Loss, Palpitations
Anxiety, unintended weight loss, and palpitations are symptoms typically associated with hyperthyroidism, not hypothyroidism. Hyperthyroidism occurs when the thyroid gland produces excessive thyroid hormones, leading to an accelerated metabolism. This results in symptoms such as weight loss, increased heart rate (palpitations), and anxiety. Elevated TSH levels would not be expected in hyperthyroidism; instead, TSH levels would be low due to negative feedback from high thyroid hormone levels.
Choice D reason: Shakiness, Sweating, Nausea
Shakiness, sweating, and nausea can be symptoms of various conditions, including hypoglycemia (low blood sugar), anxiety, or panic attacks. These symptoms are not specific to thyroid dysfunction and are not typically associated with elevated TSH levels. Hypothyroidism, indicated by high TSH levels, usually presents with symptoms related to a slowed metabolism, such as fatigue and weight gain, rather than shakiness and sweating.
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