A nurse is teaching a client who has peripheral arterial disease. Which of the following statements should the nurse include in the teaching to explain peripheral arterial disease?
"Blood flow is altered and causes blood to pool in the legs."
"Blood flow is altered due to atherosclerosis affecting the tissues' ability to receive oxygen-rich blood."
"Blood flow is altered due to incompetent valves causing increased venous pressure."
"Blood flow is altered due to excessive stretching of the ventricles impairing the heart to contract."
The Correct Answer is B
A. "Blood flow is altered and causes blood to pool in the legs." This statement inaccurately describes venous insufficiency rather than peripheral arterial disease (PAD). In PAD, blood flow is reduced or obstructed due to atherosclerosis, leading to inadequate oxygen supply to tissues rather than pooling of blood in the legs.
B. "Blood flow is altered due to atherosclerosis affecting the tissues' ability to receive oxygen-rich blood." This statement correctly explains the underlying pathology of peripheral arterial disease (PAD). Atherosclerosis, characterized by the buildup of plaque in the arteries, narrows or blocks blood flow, impairing the delivery of oxygen-rich blood to the tissues. This can result in symptoms such as pain, cramping, and tissue damage, especially during activity when oxygen demand increases.
C. "Blood flow is altered due to incompetent valves causing increased venous pressure." This statement describes venous insufficiency rather than PAD. In venous insufficiency, faulty valves in the veins result in increased venous pressure, leading to symptoms such as swelling, heaviness, and varicose veins, but it does not involve arterial obstruction as seen in PAD.
D. "Blood flow is altered due to excessive stretching of the ventricles impairing the heart to contract." This statement describes a condition related to the heart's function rather than peripheral arterial disease. Excessive stretching of the ventricles may occur in conditions such as heart failure, but it does not directly affect blood flow in the peripheral arteries as seen in PAD.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) "Pentoxifylline can be administered to help the platelets from sticking together and occluding the vessels": Pentoxifylline is a medication used to improve blood flow by decreasing the viscosity of blood. However, it is not typically used to treat mitral valve stenosis. This statement does not accurately reflect treatment options for this condition.
B) "A heparin bolus is administered and followed with a continuous infusion to help keep the blood thinner": Heparin is an anticoagulant used to prevent blood clot formation, but it is not a treatment for mitral valve stenosis itself. While anticoagulants may be used in certain situations with mitral valve stenosis (such as in the setting of atrial fibrillation), they do not directly address the underlying valve narrowing.
C) "A flexible catheter will be inserted into a vessel of the arm, neck, or groin and advanced to the heart to dilate a narrowed or occluded artery": This statement describes a procedure known as percutaneous transluminal mitral valvuloplasty (PTMV), which is a minimally invasive intervention used to treat mitral valve stenosis. During this procedure, a catheter with a deflated balloon on its tip is inserted into a vessel and guided to the heart, where the balloon is inflated to widen the narrowed valve.
D) "A small catheter with a balloon on the end is threaded into a vessel in the groin and advanced to the heart where the balloon will be inflated, and the narrowed valve will be dilated": This statement accurately describes balloon valvuloplasty, which is a common procedure used to treat mitral valve stenosis. By inflating the balloon within the narrowed valve, the procedure aims to widen the valve opening, thus improving blood flow through the heart.
Correct Answer is D
Explanation
A. Comply with compression therapy:
Compression therapy typically refers to the use of compression garments or devices to improve circulation and reduce swelling in the extremities, particularly in conditions such as venous insufficiency or deep vein thrombosis.
While compression therapy may be beneficial for certain circulatory disorders, it is not a standard treatment for cardiac tamponade.
Cardiac tamponade is a medical emergency characterized by the accumulation of fluid in the pericardial sac, leading to increased pressure on the heart and impaired cardiac function.
Treatment for cardiac tamponade involves prompt recognition and intervention to relieve the pressure on the heart, such as pericardiocentesis or surgical drainage of the pericardial effusion.
B. Monitor wounds on lower extremities:
Monitoring wounds on the lower extremities is essential for assessing healing, preventing complications such as infection, and promoting overall wound care.
However, monitoring wounds on the lower extremities is not directly related to the management or monitoring of cardiac tamponade.
In cardiac tamponade, the focus of monitoring is on assessing signs and symptoms of cardiac compromise, such as hypotension, tachycardia, dyspnea, and pulsus paradoxus, rather than wound care.
C. Take antiplatelet medications as ordered:
Antiplatelet medications, such as aspirin or clopidogrel, are commonly prescribed to prevent platelet aggregation and reduce the risk of thrombotic events, particularly in patients with cardiovascular disease or a history of myocardial infarction or stroke.
While antiplatelet medications may be part of the long-term management of certain cardiac conditions, they are not specific to the treatment or monitoring of cardiac tamponade.
The primary treatment for cardiac tamponade involves interventions to relieve the pressure on the heart and restore cardiac function, such as pericardiocentesis or surgical drainage of the pericardial effusion.
D. Monitor for gradual onset of symptoms:
Phase II of cardiac tamponade is characterized by a gradual onset of symptoms as the pressure within the pericardial sac increases, leading to impaired cardiac filling and decreased cardiac output.
Symptoms may include dyspnea, fatigue, orthopnea, tachycardia, and chest discomfort, which may develop gradually over time.
Early recognition of symptoms is crucial for prompt diagnosis and intervention to prevent further deterioration and improve outcomes in patients with cardiac tamponade.
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