The nurse is collecting data on a patient with bilateral acute venous insufficiency. Which of the following clinical manifestations would be a priority for the nurse to report?

Bilateral edema of the legs

Bilateral hyperemia of the legs

Bilateral full superficial leg veins

Left leg cool, cyanotic skin

Answer and Explanation

The Correct Answer is D

A. Bilateral edema of the legs: While significant, bilateral edema is a common symptom of venous insufficiency and generally less urgent compared to signs of compromised circulation.
B. Bilateral hyperaemia of the legs: Hyperaemia (increased blood flow) is less concerning compared to cyanosis and coolness, which suggest severe impairment.
C. Bilateral full superficial leg veins: Prominent veins are typical in venous insufficiency and do not indicate an immediate threat.
D. Left leg cool, cyanotic skin: This is correct. Cool, cyanotic skin indicates poor perfusion and potential arterial involvement or severe venous congestion, requiring urgent assessment to prevent tissue damage.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is ["A","D","F"]

Explanation

A. Have the patient swallow twice after each bite: This can help clear any residual food from the mouth and reduce the risk of aspiration.
B. Place the patient in a semi-Fowler position: This position is not ideal for preventing aspiration. The patient should be in an upright, high Fowler’s position to minimize the risk.
C. Provide clear liquids only until the patient can swallow solid foods: Clear liquids can actually be more difficult to control in the mouth and throat than thicker liquids and may increase the risk of aspiration.
D. Check the patient's mouth for pocketing of food: Ensuring that no food is left in the mouth can help prevent aspiration after the patient has finished eating.
E. Encourage the use of a straw for liquids: Using a straw can increase the risk of aspiration because it delivers liquids quickly and may overwhelm the swallowing mechanism, especially in patients with dysphagia.
F. Place food on the unaffected side of the patient's mouth: This helps ensure that the stronger side of the mouth and throat manages the food, reducing the risk of aspiration.

A. Incontinence (bowel or urinary) B. Impaired skin integrity C. Disturbed sensory perception D. Imbalanced nutrition

Correct Answer is C

Explanation

A. Incontinence (bowel or urinary): While incontinence may occur in stroke patients, it is not the primary concern for someone with hemianopsia, a visual impairment.
B. Impaired skin integrity: Although this is important, particularly for immobile patients, it is not directly related to hemianopsia.
C. Disturbed sensory perception: Hemianopsia results in the loss of half the field of vision in one or both eyes, leading to disturbed sensory perception. This is a priority because it directly affects the patient's ability to navigate their environment safely.
D. Imbalanced nutrition: Although important, this is not the immediate concern related to hemianopsia.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

The nurse is collecting data on a patient with bilateral acute venous insufficiency. Which of the following clinical manifestations would be a priority for the nurse to report?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient is having difficulty swallowing following a stroke, and a swallowing evaluation is ordered. Which nursing interventions might be recommended to help prevent aspiration during eating? Select all that apply. (Select All that Apply.)

Correct Answer is ["A","D","F"]

Explanation

The nurse is caring for a patient suffering from left-sided hemianopsia after having a stroke. Which nursing diagnosis is priority for this patient?

Correct Answer is C

Explanation

The nurse assists with care of a confused patient who presents to the emergency department with stroke symptoms. Vital signs are blood pressure 174/100 mm Hg. pulse 64 beats per minute, and SpO2 88% on room air. Which nursing intervention is priority?

A patient asks the difference between osteoarthritis and RA. Which manifestations does the nurse explain are characteristic of RA? (Select all that apply.)

A nurse in an outpatient clinic is collecting data from a client who tells the nurse, "I have pain in my legs when I begin to walk, but the pain stops when I stop walking." Which of the following conditions should the nurse suspect?

The nurse is teaching a patient about a thiazide-like diuretic. Which statement made by the patient indicates an understanding of the teaching?

A patient with osteoarthritis who had a right total knee replacement tells the nurse that the other knee is becoming painful. Which of the following is the most appropriate instruction to help the patient preserve function of the left knee?

The nurse is caring for a patient with a blunt trauma and tissue injury to the lower extremity. Which signs could develop in a patient with compartment syndrome?

A patient who is diagnosed with a stroke is requesting a glass of water. Which action is appropriate for the nurse to take?