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A nurse is reinforcing teaching to a client who has peripheral venous disease about management of symptoms. Which of the following client statements indicates to the nurse an understanding of the teaching?

A.

“I will decrease my activity to prevent added stress on my legs."

B.

“I will need to massage my legs frequently to prevent a buildup of fluid."

C.

“I will inspect my legs every day for changes in color, size, and temperature."

D.

“I will keep my legs in a dependent position."

Answer and Explanation

The Correct Answer is C

A. Decreasing activity is not advisable; clients with peripheral venous disease should engage in regular, moderate exercise to improve venous circulation.  

 

B. Massaging the legs is not recommended as it can exacerbate venous insufficiency and potentially lead to complications such as thrombosis.  

 

C. Inspecting the legs daily for changes in color, size, and temperature is crucial for early detection of complications and indicates an understanding of self-monitoring.  

 

D. Keeping the legs in a dependent position can worsen venous pooling; the client should elevate their legs when resting to promote venous return.


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Correct Answer is D

Explanation

A. While coronary arteries may change with age, the increased elasticity does not lead to insufficient oxygen; rather, it can affect their ability to respond to increased demand.

B. Weakening of the heart can contribute to heart failure but is not a direct explanation for how coronary artery disease causes angina.

C. Dilation of coronary arteries typically does not cause manifestations in coronary artery disease; instead, it is the narrowing (stenosis) that leads to issues.

D. Decreased diameter of the coronary arteries due to atherosclerosis is the primary issue in coronary artery disease, which leads to inadequate blood supply, oxygen, and nutrients to the heart muscle, causing symptoms like angina.

Correct Answer is C

Explanation

A. Monitoring electrolyte levels is important but is not as immediate as ensuring airway patency.

B. Performing passive range of motion is beneficial for mobility but does not address the immediate needs of an unconscious patient.

C. Suctioning saliva from the client's mouth is the highest priority intervention, as maintaining airway clearance is critical to prevent aspiration and ensure adequate ventilation.

D. Recording intake and output is necessary for overall assessment but is not as urgent as managing the airway.

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