vSim Health Assessment | Mona Hernandez (Cardiovascular Assessment) with correct answers

The nurse is performing an assessment of the peripheral vascular system and notes edema in one of the lower extremities. Which are causes of unilateral edema of the lower extremities? Venous stasis and obstruction Rationale: CHF and prolonged standing may cause bilateral edema. Being in a cast for a prolonged time may cause muscular atrophy. The nurse is assessing a patient for clinical manifestations of venous insufficiency. Which of the following is a characteristic of venous insufficiency? Aching, cramping pain Rationale: Dry and shiny skin, thickened nails, and cool temperature of skin are characteristics of arterial insufficiency. The nurse is providing education to a hospitalized patient on methods to prevent peripheral vascular complications. Which would the nurse include? (Select all that apply.) a. Avoid prolonged sitting with your legs in a dependent position. c. Perform active ROM exercises of your feet and ankles while in bed. d. You may have to take an anticoagulant by injection. f. Avoid crossing your legs. The nurse is caring for a patient who has developed a DVT in the left lower extremity. Which are appropriate nursing interventions to implement for a patient with a DVT? (Select all that apply.) d. Provide prescribed pain medication as needed and monitor effects. e. Perform regular assessments on the affected leg for changes in color, pulses, pain, or sensation. f. Administer anticoagulants and oxygen therapy as prescribed, and monitor effects. Rationale: Although elastic compression stockings and sequential compression devices are important preventive measures for DVT, they should be removed on diagnosis of DVT; they may be reapplied once the pain and edema of the affected extremity have resolved. Which of the following is a factor that increases the risk of DVT for Mona Hernandez? Immobility The nurse is preparing to call the provider regarding Mona Hernandez's new onset of redness, swelling, and pain in the left lower extremity. In addition to using SBAR format in communication, which of the following is most important for the nurse to do to prevent communication errors when telephoning the health care provider about the patient's change in condition? Write down and read back any orders received or information shared.