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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View Related questions
Correct Answer is C
Explanation
Choice A: Tell the client to expect dark stools following chemotherapy
Dark stools are not a common side effect of chemotherapy. This symptom is more often associated with gastrointestinal bleeding or the use of certain medications, such as iron supplements or bismuth-containing compounds. Chemotherapy can cause a range of side effects, but dark stools are not typically one of them. Therefore, it is not necessary to inform the client to expect this symptom.
Choice B: Have the client swish with commercial mouthwash before therapy
While maintaining oral hygiene is important during chemotherapy, using a commercial mouthwash before therapy is not specifically recommended. Some commercial mouthwashes contain alcohol or other irritants that can exacerbate oral mucositis, a common side effect of chemotherapy. Instead, clients are often advised to use a gentle, alcohol-free mouthwash or a saline rinse to maintain oral hygiene and prevent infections.
Choice C: Administer an antiemetic prior to the procedure
Administering an antiemetic prior to chemotherapy is a standard practice to prevent nausea and vomiting, which are common side effects of many chemotherapeutic agents. Antiemetics help to improve the client’s comfort and adherence to the treatment regimen by reducing these distressing symptoms. This proactive approach is crucial in managing the side effects of chemotherapy and ensuring that the client can tolerate the treatment.
Choice D: Have the client floss 4 times daily
Flossing is an important part of oral hygiene, but flossing 4 times daily is excessive and can cause irritation or damage to the gums, especially in clients undergoing chemotherapy who may have a higher risk of oral mucositis and bleeding. It is generally recommended to floss once daily and to use a soft-bristled toothbrush to maintain oral health without causing additional trauma.
Correct Answer is D
Explanation
Choice A reason:
A client with a tracheostomy tube attached to humidified oxygen is not typically at risk for hypokalemia. The primary concerns for these clients are maintaining a patent airway, preventing infection, and ensuring adequate humidification to prevent mucus plugging.
Choice B reason:
A client with an indwelling urinary catheter to gravity drainage is not specifically at risk for hypokalemia. The main risks for these clients include urinary tract infections and ensuring proper catheter care to prevent blockages.
Choice C reason:
A client with a chest tube to water seal is primarily at risk for complications related to the chest tube itself, such as infection, pneumothorax, or improper drainage. Hypokalemia is not a common risk associated with chest tubes.
Choice D reason:
A client with a nasogastric tube to suction is at risk for hypokalemia. Continuous suctioning can lead to the loss of gastric contents, which contain potassium, leading to a decrease in potassium levels in the body. This can result in hypokalemia, which needs to be monitored and managed appropriately.
