Brunner and Suddarth's Textbook of Medical
Surgical Nursing; Chapter 30: Assessment &
Management of Patients With Vascular
Disorders
A 79yearold man is admitted to the medical unit with digital gangrene. The man states that his problems
first began when he stubbed his toe going to the bathroom in the dark. In addition to this trauma, the
nurse should suspect that the patient has a history of what health problem?
- Raynaud's phenomenon
- CAD
- Arterial insufficiency
- Varicose veins - correct answer- Arterial insufficiency
Feedback: Arterial insufficiency may result in gangrene of the toe (digital gangrene), which usually is
caused by trauma. The toe is stubbed and then turns black. Raynaud's, CAD and varicose veins are not
the usual causes of digital gangrene in the elderly.
A medical nurse has admitted four patients over the course of a 12hour shift. For which patient would
assessment of anklebrachial index (ABI) be most clearly warranted?
-A patient who has peripheral edema secondary to chronic heart failure
-An older adult patient who has a diagnosis of unstable angina
-A patient with poorly controlled type 1 diabetes who is a smoker
,- A patient who has communityacquired pneumonia and a history of COPD - correct answer-A patient
with poorly controlled type 1 diabetes who is a smoker
Feedback: Nurses should perform a baseline ABI on any patient with decreased pulses or any patient 50
years of age or older with a history of diabetes or smoking. The other answers do not apply.
A nurse has written a plan of care for a man diagnosed with peripheral arterial insufficiency. One of the
nursing diagnoses in the care plan is altered peripheral tissue perfusion related to compromised
circulation. What is the most appropriate intervention for this diagnosis?
-Elevate his legs and arms above his heart when resting.
-Encourage the patient to engage in a moderate amount of exercise.
-Encourage extended periods of sitting or standing.
-Discourage walking in order to limit pain. - correct answeranswer: Encourage the patient to engage in a
moderate amount of exercise.
Feedback: The nursing diagnosis of altered peripheral tissue perfusion related to compromised
circulation requires interventions that focus on improving circulation. Encouraging the patient to engage
in a moderate amount of exercise serves to improve circulation. Elevating his legs and arms above his
heart when resting would be passive and fails to promote circulation. Encouraging long periods of sitting
or standing would further compromise circulation. The nurse should encourage, not discourage, walking
to increase circulation and decrease pain.
A nurse in a longterm care facility is caring for an 83yearold woman who has a history of HF and
peripheral arterial disease (PAD). At present the patient is unable to stand or ambulate. The nurse
should implement measures to prevent what complication?
-Aoritis
-Deep vein thrombosis
, -Thoracic aortic aneurysm
-Raynaud's disease - correct answeranswer: deep vein thrombosis
Feedback: Although the exact cause of venous thrombosis remains unclear, three factors, known as
Virchow's triad, are believed to play a significant role in its development: stasis of blood (venous stasis),
vessel wall injury, and altered blood coagulation. In this woman's case, she has venous stasis from
immobility, vessel wall injury from PAD, and altered blood coagulation from HF. The cause of aoritis is
unknown, but it has no direct connection to HF, PAD, or mobility issues. The greatest risk factors for
thoracic aortic aneurysm are atherosclerosis and hypertension; there is no direct connection to HF, PAD,
or mobility issues. Raynaud's disease is a disorder that involves spasms of blood vessels and, again, no
direct connection to HF, PAD, or mobility issues.
A nurse in the rehabilitation unit is caring for an older adult patient who is in cardiac rehabilitation
following an MI. The nurse's plan of care calls for the patient to walk for 10 minutes 3 times a day. The
patient questions the relationship between walking and heart function. How should the nurse best
reply?
-"The arteries in your legs constrict when you walk and allow the blood to move faster and with more
pressure on the tissue."
-Walking increases your heart rate and blood pressure. Therefore your heart is under less stress."
-"Walking helps your heart adjust to your new arteries and helps build your selfesteem."
-"When you walk, the muscles in your legs contract and pump the blood in your veins back toward your
heart, which allows more blood to return to your heart." - correct answeranswer:
"When you walk, the muscles in your legs contract and pump the blood in your veins back toward your
heart, which allows more blood to return to your heart."
Feedback: Veins, unlike arteries, are equipped with valves that allow blood to move against the force of
gravity. The legs have oneway bicuspid valves that prevent blood from seeping backward as it moves
forward by the muscles in our legs pressing on the veins as we walk and increasing venous return. Leg
Surgical Nursing; Chapter 30: Assessment &
Management of Patients With Vascular
Disorders
A 79yearold man is admitted to the medical unit with digital gangrene. The man states that his problems
first began when he stubbed his toe going to the bathroom in the dark. In addition to this trauma, the
nurse should suspect that the patient has a history of what health problem?
- Raynaud's phenomenon
- CAD
- Arterial insufficiency
- Varicose veins - correct answer- Arterial insufficiency
Feedback: Arterial insufficiency may result in gangrene of the toe (digital gangrene), which usually is
caused by trauma. The toe is stubbed and then turns black. Raynaud's, CAD and varicose veins are not
the usual causes of digital gangrene in the elderly.
A medical nurse has admitted four patients over the course of a 12hour shift. For which patient would
assessment of anklebrachial index (ABI) be most clearly warranted?
-A patient who has peripheral edema secondary to chronic heart failure
-An older adult patient who has a diagnosis of unstable angina
-A patient with poorly controlled type 1 diabetes who is a smoker
,- A patient who has communityacquired pneumonia and a history of COPD - correct answer-A patient
with poorly controlled type 1 diabetes who is a smoker
Feedback: Nurses should perform a baseline ABI on any patient with decreased pulses or any patient 50
years of age or older with a history of diabetes or smoking. The other answers do not apply.
A nurse has written a plan of care for a man diagnosed with peripheral arterial insufficiency. One of the
nursing diagnoses in the care plan is altered peripheral tissue perfusion related to compromised
circulation. What is the most appropriate intervention for this diagnosis?
-Elevate his legs and arms above his heart when resting.
-Encourage the patient to engage in a moderate amount of exercise.
-Encourage extended periods of sitting or standing.
-Discourage walking in order to limit pain. - correct answeranswer: Encourage the patient to engage in a
moderate amount of exercise.
Feedback: The nursing diagnosis of altered peripheral tissue perfusion related to compromised
circulation requires interventions that focus on improving circulation. Encouraging the patient to engage
in a moderate amount of exercise serves to improve circulation. Elevating his legs and arms above his
heart when resting would be passive and fails to promote circulation. Encouraging long periods of sitting
or standing would further compromise circulation. The nurse should encourage, not discourage, walking
to increase circulation and decrease pain.
A nurse in a longterm care facility is caring for an 83yearold woman who has a history of HF and
peripheral arterial disease (PAD). At present the patient is unable to stand or ambulate. The nurse
should implement measures to prevent what complication?
-Aoritis
-Deep vein thrombosis
, -Thoracic aortic aneurysm
-Raynaud's disease - correct answeranswer: deep vein thrombosis
Feedback: Although the exact cause of venous thrombosis remains unclear, three factors, known as
Virchow's triad, are believed to play a significant role in its development: stasis of blood (venous stasis),
vessel wall injury, and altered blood coagulation. In this woman's case, she has venous stasis from
immobility, vessel wall injury from PAD, and altered blood coagulation from HF. The cause of aoritis is
unknown, but it has no direct connection to HF, PAD, or mobility issues. The greatest risk factors for
thoracic aortic aneurysm are atherosclerosis and hypertension; there is no direct connection to HF, PAD,
or mobility issues. Raynaud's disease is a disorder that involves spasms of blood vessels and, again, no
direct connection to HF, PAD, or mobility issues.
A nurse in the rehabilitation unit is caring for an older adult patient who is in cardiac rehabilitation
following an MI. The nurse's plan of care calls for the patient to walk for 10 minutes 3 times a day. The
patient questions the relationship between walking and heart function. How should the nurse best
reply?
-"The arteries in your legs constrict when you walk and allow the blood to move faster and with more
pressure on the tissue."
-Walking increases your heart rate and blood pressure. Therefore your heart is under less stress."
-"Walking helps your heart adjust to your new arteries and helps build your selfesteem."
-"When you walk, the muscles in your legs contract and pump the blood in your veins back toward your
heart, which allows more blood to return to your heart." - correct answeranswer:
"When you walk, the muscles in your legs contract and pump the blood in your veins back toward your
heart, which allows more blood to return to your heart."
Feedback: Veins, unlike arteries, are equipped with valves that allow blood to move against the force of
gravity. The legs have oneway bicuspid valves that prevent blood from seeping backward as it moves
forward by the muscles in our legs pressing on the veins as we walk and increasing venous return. Leg
