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:
The statement “This stage is when testing occurs to identify boundaries of interpersonal behaviors” describes the storming stage of group development. During the storming stage, group members test boundaries and challenge each other, leading to conflicts and disagreements.
Choice B reason:
The norming stage is characterized by the development of group cohesion and consensus. During this stage, group members start to resolve their differences, appreciate each other’s strengths, and work together more effectively. Consensus evolves as the group establishes norms and agrees on common goals.
Choice C reason:
While constructive efforts are part of the norming stage, the statement is too vague to indicate a clear understanding of this specific stage. Constructive efforts can occur in various stages of group development, including performing.
Choice D reason:
Resistance and the formation of subgroups are typical of the storming stage, not the norming stage. In the storming stage, conflicts and power struggles are common as group members assert their opinions and roles.
Correct Answer is A
Explanation
Choice A: Hemorrhage
Hemorrhage is a significant and immediate postoperative complication following a transurethral resection of the prostate (TURP). This procedure involves removing part of the prostate gland, which can lead to bleeding. Monitoring for signs of hemorrhage, such as a significant drop in blood pressure, increased heart rate, and visible blood in the urine, is crucial. Early detection and intervention are essential to manage bleeding and prevent severe complications. Hemorrhage can lead to hypovolemic shock if not addressed promptly, making it the priority complication to monitor for.
Choice B: Infection
Infection is a common postoperative complication, but it typically develops a few days after surgery rather than immediately. Signs of infection include fever, chills, and increased white blood cell count. While it is important to monitor for infection, it is not the immediate priority compared to hemorrhage. Preventive measures, such as maintaining sterile techniques and administering prophylactic antibiotics, can help reduce the risk of infection.
Choice C: Urinary retention
Urinary retention can occur after TURP due to swelling or blood clots obstructing the urethra. This condition can cause discomfort and increase the risk of bladder damage. Monitoring for urinary retention involves assessing the client’s ability to void and checking for bladder distention. While it is an important complication to monitor, it is not as immediately life-threatening as hemorrhage.
Choice D: Pain
Pain is a common postoperative symptom and should be managed effectively to ensure the client’s comfort and recovery. However, pain management is typically addressed through prescribed analgesics and is not considered a life-threatening complication. Monitoring for pain and providing appropriate pain relief are essential aspects of postoperative care, but they do not take precedence over monitoring for hemorrhage.