MCA II Exam 2

MCA II Exam 2
Which clinical finding would the nurse expect to identify when caring for a client with a
left leg venous thrombosis? select all that apply.
a. pain in the left calf
b. intermittent claudication
c. redness in the affected area
d. swelling of the lower left leg
e. ecchymotic areas at the left ankle
f. localized warmth in the lower left leg
A, C, D, F
pain is related to the edema associated with the inflammatory response. Redness is
related to vasodilation and the inflammatory response. Edema distal to the venous
thrombosis occurs because of increased venous pressure. Warmth in the affected part
of the leg occurs due to the inflammatory response. Intermittent claudication (pain when
walking, resulting from tissue ischemia) may occur with peripheral arterial disease.
Ecchymosis is a sign of bleeding and would not be seen with venous thrombosis.
A nurse is caring for a client admitted with cardiovascular disease. During the
assessment of the client's lower extremities, the nurse notes that the client has thin,
shiny skin, decreased hair growth, and thickened toenails. The nurse understands that
this may indicate:
a. Venous insufficiency
b. Arterial Insufficiency
c. Phlebitis
d. Lymphedema
clients experiencing arterial insufficiency present with extremities that become pale
when elevated and dusky red when lowered. Lower extremities may also be cool to
touch, pulses may be absent or mild, and skin may be shiny and thin with decreased
hair growth and thickened nails. Clients with venous insufficiency often have normalcolored extremities, normal temperature, normal pulses, marked edema, and brown
pigmentation around the ankles. Phlebitis is an inflammation of a vein that occurs most
often after trauma to the vessel wall, infection, and immobilization. Lymphedema is
swelling in one or more extremities that is a direct result of impaired flow of the
lymphatic system.
A client is admitted to the hospital with a long history of uncontrolled hypertension.
which laboratory result will be important for the nurse to review?
a. blood glucose level
b. white blood cell count
c. blood urea nitrogen
d. lactic dehydrogenase

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