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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 A

Explanation

Choice A reason: Place a black tag on the client’s upper body and attempt to help the next client in need:

In mass casualty incidents, triage is used to prioritize treatment based on the severity of injuries and the likelihood of survival. A black tag indicates that the victim is deceased or has injuries that are not compatible with life and that resources should be directed to those who have a better chance of survival. Since the client remains apneic even after repositioning the airway, it indicates that they are not breathing and have a very low chance of survival.

Choice B reason: Reposition the client’s upper airway a second time before assessing his respirations:

While ensuring the airway is open is crucial, if the client remains apneic after the initial repositioning, further attempts are unlikely to be successful in a mass casualty scenario where time and resources are limited2. The priority is to move on to other victims who may have a higher chance of survival.

Choice C reason: Start CPR:

In a mass casualty situation, CPR is typically not initiated for victims who are apneic and pulseless due to the need to allocate resources to those who have a higher likelihood of survival3. The focus is on providing immediate care to those who can benefit the most from it.

Choice D reason: Place a red tag on the client’s upper body and obtain immediate help from other personnel:

A red tag is used for victims who require immediate life-saving interventions and have a high chance of survival if treated promptly4. Since the client is apneic and remains so after airway repositioning, they do not meet the criteria for a red tag.

Correct Answer is D

Explanation

Choice A: Painful urination

Painful urination, or dysuria, is not a typical symptom of benign prostatic hyperplasia (BPH). BPH primarily affects the flow of urine due to the enlargement of the prostate gland, which can obstruct the urethra. While BPH can cause discomfort, it does not usually result in painful urination. Painful urination is more commonly associated with urinary tract infections (UTIs) or other conditions affecting the urinary tract.

Choice B: Urge incontinence

Urge incontinence, characterized by a sudden and intense urge to urinate followed by involuntary loss of urine, can occur in some cases of BPH but is not the most common symptom. BPH typically causes symptoms related to urinary obstruction, such as difficulty starting urination, weak urine stream, and incomplete bladder emptying. Urge incontinence may develop if the bladder becomes overactive due to the obstruction, but it is not a primary symptom.

Choice C: Critically elevated prostate-specific antigen (PSA) level

While an elevated prostate-specific antigen (PSA) level can be associated with BPH, it is not a definitive finding. PSA levels can be elevated due to various conditions, including prostate cancer, prostatitis, and BPH. However, a critically elevated PSA level is more concerning for prostate cancer rather than BPH. Therefore, while PSA testing is useful in the evaluation of prostate conditions, it is not specific to BPH.

Choice D: Difficulty starting the flow of urine

Difficulty starting the flow of urine, also known as hesitancy, is a hallmark symptom of BPH. The enlarged prostate gland can compress the urethra, making it difficult for urine to pass through. This can lead to a weak urine stream, straining to urinate, and a feeling of incomplete bladder emptying. These symptoms are collectively known as lower urinary tract symptoms (LUTS) and are commonly associated with BPH.