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9 Cards in this Set
- Front
- Back
- 3rd side (hint)
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The nurse is working with a client who has just been diagnosed with an aneurysm. What advice should the nurse provide to this client?
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Avoid straining during bowel movements and coughing.
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RATIONAL:
The nurse advises the client with an aneurysm to avoid straining during bowel movements and coughing. The client with Raynaud's disease is asked to avoid situations that contribute to ischemic episodes and to wear wool socks and mittens during cold weather |
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A nurse is caring for a client who's had gastric bypass surgery. The physician encourages the client to increase mobility as soon as possible. The nurse notes edema to the right leg with skin color changes to the right lower extremity. The client reports pain at the incision site as 3 on a 0- to 10-point scale and pain to the right calf as 7 on a 0- to 10-point scale. The nurse reports the findings to the physician. She suspects that the client has:
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Deep Vein Thrombosis
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What are risk factors related to venous stasis for DVT and pulmonary embolism?
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Obesity
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RATIONAL:
Obesity is a risk factor for DVT and PE related to venous stasis. |
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A home health nurse is seeing an elderly male client for the first time. During the physical assessment of the skin on the lower legs, the nurse notes edema, brown pigmentation in the gater area, pedal pulses, and a few irregularly shaped ulcers around the ankles. From these findings, the nurse knows that the client has a problem with peripheral circulation. What does the nurse suspect?
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Venous insufficiency
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RATIONAL:
Symptoms of venous insufficiency include present pedal pulses, edema, pigmentation in gater area, and a reddish blue color. Ulcers caused by venous insufficiency will be irregular in shape and usually located around the ankles or the anterior tibial area. Characteristics of arterial insufficiency ulcers include location at the tips of the toes, great pain, and circular shape with a pale to black ulcer base. |
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A client who underwent total hip replacement exhibits a red, painful area on the calf of the affected leg. What test validates presence of thromboembolism?
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Homans'
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RATIONAL:
A positive Homans' sign, or pain in the calf elicited upon flexion of the ankle with the leg straight, indicates the presence of a thrombus. |
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What medication is considered a thrombolytic?
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Alteplase
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RATIONAL:
Alteplase is considered a thrombolytic, which lyses and dissolves thrombi. Thrombolytic therapy is most effective when given within the first 3 days after acute thrombosis. |
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The nurse is caring for a client who is status post operative from a vein stripping. What would the nurse monitor for?
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Swelling in the operative leg
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RATIONAL:
When the client returns from surgery with a gauze dressing covered by elastic roller bandages on the operative leg, the nurse monitors for swelling in the operative leg(s) and its effect on circulation |
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What is a characteristic of an arterial ulcer?
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Border regular and well demarcated
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RATIONAL:
Characteristics of an arterial ulcer include a border that is regular and demarcated. |
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What is the most common site for a dissecting aneurysm?
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Thoracic area
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RATIONAL:
The thoracic area is the most common site for a dissecting aneurysm. About one-third of patients with thoracic aneurysms die of rupture of the aneurysm. |
