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A nurse is assessing a client who has chronic venous insufficiency. Which of the following findings should the nurse expect?

A.

Dependent rubor

B.

Thick, deformed toenails

C.

Hair loss

D.

Edema

Answer and Explanation

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.

 


View Related questions

Correct Answer is C

Explanation

Choice A: Ulnar Deviation

Ulnar deviation, or the bending of the fingers towards the ulna (the outer bone of the forearm), is more commonly associated with rheumatoid arthritis rather than osteoarthritis. Rheumatoid arthritis typically affects the joints symmetrically and can lead to deformities such as ulnar deviation due to chronic inflammation.

Choice B: Symmetric Joints Affected

Symmetric joint involvement is characteristic of rheumatoid arthritis, not osteoarthritis. Osteoarthritis usually affects joints asymmetrically, meaning it can affect one joint more than the other. It commonly affects weight-bearing joints such as the knees, hips, and spine.

Choice C: Pain Worsens with Activity

Pain that worsens with activity is a hallmark symptom of osteoarthritis. This condition is caused by the breakdown of cartilage in the joints, leading to pain and stiffness, especially after physical activity. The pain typically improves with rest but can become more persistent as the disease progresses.

Choice D: Weight Loss

Weight loss is not a typical manifestation of osteoarthritis. In fact, being overweight or obese is a risk factor for developing osteoarthritis, particularly in weight-bearing joints. Weight management is often recommended to help reduce the stress on affected joints and alleviate symptoms.

Correct Answer is A

Explanation

Choice A: Obtain a 12-lead ECG

Obtaining a 12-lead ECG is a critical action when a client has a potassium level of 6.8 mEq/L, which indicates hyperkalemia. Hyperkalemia can cause serious cardiac dysrhythmias, including life-threatening arrhythmias such as ventricular fibrillation or asystole. An ECG can help detect these abnormalities early, allowing for prompt intervention to prevent cardiac complications. The ECG may show characteristic changes such as peaked T waves, widened QRS complexes, and prolonged PR intervals, which are indicative of hyperkalemia.

Choice B: Suggest that the client use a salt substitute

Suggesting that the client use a salt substitute is not appropriate in this situation. Many salt substitutes contain potassium chloride, which can further increase the potassium level in the blood. For a client with hyperkalemia, it is crucial to avoid additional sources of potassium to prevent exacerbating the condition. Therefore, recommending a salt substitute could be harmful.

Choice C: Advise the client to add citrus juices and bananas to her diet

Advising the client to add citrus juices and bananas to her diet is also inappropriate. Both citrus juices and bananas are high in potassium and can contribute to an increase in serum potassium levels. For a client with hyperkalemia, it is essential to limit dietary potassium intake to help lower the potassium levels in the blood. Encouraging the consumption of high-potassium foods would be counterproductive and potentially dangerous.

Choice D: Obtain a blood sample for a serum sodium level

While obtaining a blood sample for a serum sodium level can be part of a comprehensive assessment, it is not the immediate priority in managing hyperkalemia. The primary concern with a potassium level of 6.8 mEq/L is the risk of cardiac dysrhythmias. Therefore, obtaining an ECG to monitor the heart’s electrical activity is the most urgent and appropriate action. Once the immediate risk is addressed, further laboratory tests, including serum sodium levels, can be conducted as part of the overall assessment and management plan.