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 D
Explanation
Choice A: Perform a Blind Finger Sweep
Performing a blind finger sweep is not recommended because it can push the foreign object further into the airway, making the obstruction worse. This method is only advised if the object is clearly visible and can be safely removed without causing further harm.
Choice B: Turn the Client to the Side
Turning the client to the side can be helpful in certain situations, such as when the client is unconscious or at risk of vomiting. However, in the case of a conscious client with a foreign body airway obstruction, this action does not directly address the obstruction and is not the first priority.
Choice C: Insert an Oral Airway
Inserting an oral airway is typically used to maintain an open airway in an unconscious patient who cannot maintain their own airway. For a conscious client with a foreign body obstruction, this action is not appropriate and could cause further complications.
Choice D: Administer the Abdominal Thrust Maneuver
Administering the abdominal thrust maneuver (also known as the Heimlich maneuver) is the recommended first action for a conscious client with a foreign body airway obstruction. This technique involves standing behind the client, placing a fist just above their navel, and delivering quick, upward thrusts to expel the foreign object. This method is effective in creating an artificial cough that can dislodge the obstruction.
Correct Answer is B
Explanation
Choice A reason: Akathisia:
Akathisia is characterized by a feeling of inner restlessness and an inability to stay still. It often manifests as constant movement, such as pacing or fidgeting. While akathisia is a common side effect of antipsychotic medications, it does not typically involve involuntary movements of the tongue and face.
Choice B reason: Tardive dyskinesia:
Tardive dyskinesia is a serious and often irreversible side effect of long-term antipsychotic use, including chlorpromazine. It is characterized by involuntary, repetitive movements, particularly of the face, tongue, and jaw. These movements can include lip smacking, tongue protrusion, and grimacing. This condition is a result of prolonged dopamine receptor blockade in the brain.
Choice C reason: Dystonia:
Dystonia involves sustained muscle contractions that cause twisting and repetitive movements or abnormal postures. It can affect any part of the body, including the neck, face, and limbs. While dystonia can be a side effect of antipsychotic medications, it typically presents as muscle spasms rather than the repetitive, involuntary movements seen in tardive dyskinesia.