A nurse is assessing a client who has chronic venous insufficiency. Which of the following findings should the nurse expect?
Dependent rubor
Thick, deformed toenails
Hair loss
Edema
The Correct Answer is D
Choice A: Dependent rubor
Dependent rubor is a reddish discoloration of the skin that occurs when the leg is in a dependent position (hanging down). This condition is typically associated with arterial insufficiency rather than chronic venous insufficiency. Arterial insufficiency occurs when there is inadequate blood flow through the arteries, leading to symptoms such as pain, cramping, and changes in skin color. Dependent rubor is a sign of poor arterial circulation and is not commonly seen in venous insufficiency.
Choice B: Thick, deformed toenails
Thick, deformed toenails can be a sign of fungal infections or other conditions affecting the nails, but they are not specifically indicative of chronic venous insufficiency. While individuals with chronic venous insufficiency may have poor circulation that can contribute to nail problems, this symptom is not a primary or common finding associated with the condition. Instead, it is more often related to other underlying health issues.
Choice C: Hair loss
Hair loss on the legs can occur due to various reasons, including poor circulation. However, it is more commonly associated with arterial insufficiency rather than chronic venous insufficiency. In arterial insufficiency, the reduced blood flow can lead to hair loss, shiny skin, and other changes in the lower extremities. Chronic venous insufficiency primarily affects the veins and leads to symptoms such as swelling, varicose veins, and skin changes.
Choice D: Edema
Edema, or swelling, is a hallmark symptom of chronic venous insufficiency. This condition occurs when the veins in the legs are unable to effectively return blood to the heart, leading to blood pooling in the lower extremities. The increased pressure in the veins causes fluid to leak into the surrounding tissues, resulting in swelling. Edema is often more pronounced at the end of the day or after prolonged periods of standing or sitting. Managing edema is a key aspect of treating chronic venous insufficiency, and it often involves the use of compression stockings, elevation of the legs, and other measures to improve venous return.
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Correct Answer is B
Explanation
Choice A reason:
Intense pruritus: While itching (pruritus) can be a symptom of skin conditions, it is not a definitive sign of malignancy in nevi. Pruritus can be associated with benign conditions such as eczema or allergic reactions. However, if a mole starts to itch, it should be monitored closely, but it is not as strong an indicator of malignancy as irregular borders.
Choice B reason:
Irregular borders: This is a significant sign of potential malignancy in nevi. Melanomas often have uneven, notched, or scalloped borders, unlike benign moles, which typically have smooth, even borders. The irregularity in the border is due to the uncontrolled growth of melanocytes, which can spread unevenly.
Choice C reason:
Uniform pigmentation: Uniform pigmentation is generally a sign of a benign mole. Malignant moles often have multiple colors or an uneven distribution of color, which can include shades of brown, black, red, white, or blue. A mole with uniform color is less likely to be malignant.
Choice D reason:
Purulent drainage: While purulent drainage (pus) indicates an infection, it is not a typical sign of malignancy in nevi. Infections can occur in any skin lesion, but they do not specifically indicate cancer. Malignant moles are more likely to change in size, shape, or color rather than produce pus.
Correct Answer is B
Explanation
Choice A: A Client Who Has a Small Circular Partial-Thickness Burn of the Left Calf
A small circular partial-thickness burn of the left calf is considered a minor injury in the context of a mass casualty event. This type of injury does not pose an immediate threat to life and can be managed after more critical cases are addressed. In mass casualty triage, patients with minor injuries are often categorized as “green” or “minimal” and are treated last.
Choice B: A Client Who Has Severe Respiratory Stridor and a Deviated Trachea
A client with severe respiratory stridor and a deviated trachea should be assessed first. These symptoms indicate a potential airway obstruction, which is a life-threatening condition requiring immediate intervention. In mass casualty triage, patients with compromised airways are given the highest priority and are categorized as “red” or “immediate” because their condition is critical and requires urgent medical attention.
Choice C: A Client Who Has a Splinted Open Fracture of the Left Medial Malleolus
A splinted open fracture of the left medial malleolus is a serious injury but not immediately life-threatening if properly splinted. This client would be categorized as “yellow” or “delayed” in mass casualty triage, meaning they require medical attention but can wait until more critical patients are stabilized.
Choice D: A Client Who Has a Massive Head Injury and Is Experiencing Seizures
A client with a massive head injury and experiencing seizures is in a critical condition. However, in the context of mass casualty triage, the immediate priority is to secure the airway, breathing, and circulation. While this client is in dire need of medical attention, the presence of severe respiratory stridor and a deviated trachea in another client takes precedence due to the immediate threat to life.