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?
“I will decrease my activity to prevent added stress on my legs."
“I will need to massage my legs frequently to prevent a buildup of fluid."
“I will inspect my legs every day for changes in color, size, and temperature."
“I will keep my legs in a dependent position."
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 B
Explanation
A. Documenting the findings and continuing the visit does not address the potential seriousness of the weight gain and edema in a patient with heart failure. It is important to act promptly on such findings.
B. Notifying the RN case manager of the change in status is essential because a weight gain of this magnitude, along with generalized edema, may indicate worsening heart failure. This requires a timely assessment and possible adjustment of the treatment plan, including medication and fluid management.
C. While reinforcing the importance of daily weights is beneficial for long-term management, it is not an immediate intervention for the acute change in the patient’s condition.
D. Ensuring the client has been taking their prescribed diuretic is important, but the nurse should first communicate the significant changes to the RN case manager for further evaluation and intervention, as this might require a medication review or adjustment.
Correct Answer is B
Explanation
A. The ascending tracts transmit sensory information to the brain, but they do not process the information; that function is performed in the brain itself.
B. This statement accurately reflects the function of the descending tracts, which carry motor signals from the CNS to the muscles, facilitating voluntary movement.
C. Sensory receptors are located in various tissues throughout the body, including the skin and muscles, but not exclusively in the muscles.
D. Motor neurons are located in the spinal cord and peripheral nervous system, not in the dermal layer of the skin, where sensory receptors reside.