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: Turn the client every 4 hours:
Regularly turning the client can help prevent pressure ulcers and improve overall circulation, but it is not the most effective measure specifically for preventing ventilator-associated pneumonia (VAP). While repositioning can help with lung expansion and secretion clearance, oral care is more directly related to reducing VAP risk.
Choice B reason: Brush the client’s teeth with a suction toothbrush every 12 hours:
Oral care is crucial in preventing VAP. Bacteria from the mouth can easily travel to the lungs, especially in intubated patients. Using a suction toothbrush helps remove dental plaque and secretions, reducing the bacterial load and the risk of infection. This practice is a key component of VAP prevention bundles.
Choice C reason: Provide humidity by maintaining moisture within the ventilator tubing:
While maintaining humidity is important to prevent drying of the respiratory mucosa and to help with secretion clearance, it does not directly reduce the risk of VAP. Proper humidification is necessary for patient comfort and respiratory function but is not a primary VAP prevention strategy.
Choice D reason: Position the head of the client’s bed in the flat position:
Positioning the head of the bed flat can increase the risk of aspiration, which is a significant risk factor for VAP. The head of the bed should be elevated to 30-45 degrees to reduce the risk of aspiration and promote better lung expansion.
Correct Answer is C
Explanation
Choice A reason:
Promoting oral hygiene is important for preventing infection and maintaining overall health, especially after surgery involving the mouth. However, it is not the immediate priority in the postoperative period.
Choice B reason:
Ensuring adequate nutrition is crucial for healing and recovery, but it is not the most urgent concern immediately after surgery. Nutritional needs can be addressed once the client is stable and the risk of complications has been minimized.
Choice C reason:
Preventing aspiration is the priority action. After surgery for a fractured mandible with intermaxillary fixation, the client is at high risk for aspiration due to the inability to open the mouth and clear secretions effectively. Aspiration can lead to serious complications such as pneumonia, making it the most critical concern.
Choice D reason:
Relieving the client’s pain is important for comfort and recovery, but it is not the highest priority immediately after surgery. Pain management should be addressed once the client’s airway and breathing are secure.
