Chapter 38 Nursing Management Vascular Disorders Essay

4647 Words Feb 16th, 2015 19 Pages
Chapter 38: Nursing Management: Vascular Disorders
Test Bank

MULTIPLE CHOICE

1. When discussing risk factor modification for a 63-year-old patient who has a 5-cm abdominal aortic aneurysm, the nurse will focus discharge teaching on which patient risk factor?
a.
Male gender
b.
Turner syndrome
c.
Abdominal trauma history
d.
Uncontrolled hypertension

ANS: D
All of the factors contribute to the patient’s risk, but only hypertension can potentially be modified to decrease the patient’s risk for further expansion of the aneurysm.

DIF: Cognitive Level: Apply (application) REF: 842
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

2. A patient has a 6-cm thoracic aortic aneurysm that was discovered during a routine
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ANS: D
The nurse should assess for other clinical manifestations of peripheral arterial disease in a patient who describes intermittent claudication. Changes in skin color that occur in response to cold are consistent with Raynaud’s phenomenon. Tortuous veins on the legs suggest venous insufficiency. Unilateral leg swelling, redness, and tenderness indicate venous thromboembolism (VTE).

DIF: Cognitive Level: Apply (application) REF: 834
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

7. The nurse performing an assessment with a patient who has chronic peripheral artery disease (PAD) of the legs and an ulcer on the right second toe would expect to find
a.
dilated superficial veins.
b.
swollen, dry, scaly ankles.
c.
prolonged capillary refill in all the toes.
d.
a serosanguineous drainage from the ulcer.

ANS: C
Capillary refill is prolonged in PAD because of the slower and decreased blood flow to the periphery. The other listed clinical manifestations are consistent with chronic venous disease.

DIF: Cognitive Level: Apply (application) REF: 835
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

8. When evaluating the discharge teaching for a patient with chronic peripheral artery disease (PAD), the nurse determines a need for further instruction when the patient says, “I will
a.
have to buy some loose clothes that do not bind across my legs or waist.”
b.
use a heating pad on my feet at night to increase the

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