The nurse is caring for a patient who has a venous leg ulcer. The patient asks why these ulcers occur. What will the nurse explain as the cause for the development of venous ulcers?

"Your veins are not functioning properly. Lack of venous blood volume causes these ulcers"

"Your veins are weaker and blood is not moving up as it should. The congestion in your veins causes the ulcers to form.

"Because the veins are not working properly, there is not enough oxygen going to the skin of your legs."

"Your veins clogged so the body causes the arteries to swell and the excess oxygen in the blood causes the ulcers."

Answer and Explanation

The Correct Answer is B

A. "Your veins are not functioning properly. Lack of venous blood volume causes these ulcers": While venous insufficiency contributes to the development of venous ulcers, the primary issue is not necessarily a lack of venous blood volume but rather impaired venous return due to valve dysfunction.

B. "Your veins are weaker and blood is not moving up as it should. The congestion in your veins causes the ulcers to form.": This explanation accurately describes the pathophysiology of venous ulcers. Venous insufficiency leads to venous congestion, which causes increased pressure in the veins of the lower extremities. This pressure can result in the breakdown of skin and the formation of ulcers, typically around the ankles.

C. "Because the veins are not working properly, there is not enough oxygen going to the skin of your legs.": While venous insufficiency can affect tissue oxygenation to some extent, the primary mechanism leading to venous ulcers is venous congestion and increased pressure in the lower extremities, rather than insufficient oxygen delivery.

D. "Your veins clogged so the body causes the arteries to swell and the excess oxygen in the blood causes the ulcers.": This explanation does not accurately describe the pathophysiology of venous ulcers. Venous ulcers result from impaired venous return and venous congestion, not arterial swelling or excess oxygen in the blood.

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Correct Answer is A

Explanation

A. "Weigh yourself after breakfast every morning": Hydrochlorothiazide, a diuretic, can lead to fluid and electrolyte imbalances, including hyponatremia and hypokalemia. Monitoring weight daily, particularly after breakfast, helps detect any sudden weight changes that could indicate fluid retention or loss, allowing for timely intervention.

B. "Check your blood pressure anytime during the day": While monitoring blood pressure regularly is important for patients with hypertension, it is not a specific safety precaution related to taking hydrochlorothiazide. Blood pressure monitoring may be recommended, but it is not the primary safety precaution associated with this medication.

C. "Call the primary care provider if you experience any seizures": Seizures are not a common side effect of hydrochlorothiazide. Therefore, while it is important for patients to report any unusual symptoms to their healthcare provider, seizures are not specifically associated with this medication.

D. "Exercise at least twice a week": While regular exercise is beneficial for overall health, it is not a specific safety precaution related to taking hydrochlorothiazide. However, lifestyle modifications such as diet and exercise may complement medication therapy in managing hypertension.

A. Assess nutritional status with height, weight, blood urea nitrogen, transferrin, hemoglobin and hematocrit level. B. Consult with dietitian to determine patient's nutritional needs. C. Encourage patient to prepare simple meals or to obtain assistance with meal preparation if possible. D. Encourage patient to eat meals with visitors or others when possible.

Correct Answer is C

Explanation

A. Assess nutritional status with height, weight, blood urea nitrogen, transferrin, hemoglobin, and hematocrit level: This option focuses on assessing the patient's nutritional status, which is important for planning appropriate interventions. However, in a patient presenting with severe diarrhea and vomiting, the priority is to address immediate physiological needs and stabilize the patient's condition before conducting comprehensive assessments. While assessing nutritional status is important for long-term management, it is not the first action the nurse should take in this acute situation.

B. Consult with a dietitian to determine the patient's nutritional needs: Consulting with a dietitian is an important step in addressing the patient's nutritional needs, especially in cases of prolonged diarrhea and vomiting. However, in this scenario, the patient is experiencing severe symptoms that require immediate attention. Before consulting with a dietitian, the nurse should address the patient's acute symptoms and initiate interventions to manage fluid and electrolyte imbalances.

C. Encourage the patient to prepare simple meals or to obtain assistance with meal preparation if possible: This option addresses the immediate need to provide nutritional support to the patient. Encouraging the patient to consume simple, easily digestible meals or to seek assistance with meal preparation helps ensure that the patient receives adequate nutrition despite experiencing symptoms of diarrhea and vomiting. Providing practical advice on meal preparation empowers the patient to take control of their nutritional intake, which can be beneficial in managing symptoms and promoting recovery.

D. Encourage the patient to eat meals with visitors or others when possible: While social support and companionship can have a positive impact on the patient's overall well-being, including their nutritional intake, this option is not the first priority in this scenario. The patient's severe symptoms of diarrhea and vomiting require immediate attention to address fluid and electrolyte imbalances and prevent complications such as dehydration. Once the patient's condition stabilizes, encouraging social interaction during meals can be beneficial for promoting nutritional intake and emotional support.

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The nurse is caring for a patient who has a venous leg ulcer. The patient asks why these ulcers occur. What will the nurse explain as the cause for the development of venous ulcers?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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