A patient has been diagnosed with venous stasis. Which of these findings would the nurse most likely observe?
Pallor of the toes and cyanosis of the nail beds
Thin, shiny, atrophic skin
Brownish discoloration to the skin of the lower leg
Unilateral cool foot
The Correct Answer is C
A. Pallor and cyanosis: Indicative of arterial insufficiency, not venous disease.
B. Thin, shiny skin: Seen in peripheral arterial disease (PAD).
C. Brownish discoloration: Caused by hemosiderin deposits from chronic venous congestion.
D. Unilateral cool foot: Suggests acute arterial obstruction.
Nursing Test Bank
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Related Questions
Correct Answer is B
Explanation
A. Pupillary dilation when looking at a far object: While dilation occurs with distance, the question specifically refers to near vision.
B. Pupillary constriction when looking at a near object: Accommodation is the process by which the eyes adjust to focus on near objects, which includes pupillary constriction and lens thickening.
C. Changes in peripheral vision: This describes visual field testing, not accommodation.
D. Involuntary blinking in bright light: This describes the corneal reflex, not accommodation.
Correct Answer is D
Explanation
A. Constipation: This involves hardened stool in the colon, causing localized distention but no free fluid.
B. Splenomegaly: Enlargement of the spleen causes a palpable mass in the left upper quadrant but no free fluid.
C. Distended bladder: This causes suprapubic distension but does not produce a fluid wave.
D. Ascites: A positive fluid wave test indicates free fluid in the abdominal cavity, a hallmark sign of ascites. The test is performed by tapping one side of the abdomen and observing for a wave-like transmission of fluid to the opposite side.
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