Patho Patho #27

Question

The nurse receives report on a client who has a venous stasis ulcer. The nurse expects which assessment findings?

Answers

  1. Reports of pain when walking.
    • Rationale:

      This answer choice is not correct as pain with walking is associated with arterial insufficiency. This is called intermittent claudication and is a classic manifestation of arterial insufficiency.

  2. Diminished pulses in the lower extremities.
    • Rationale:

      This answer choice is not correct as diminished pulses are associated with arterial insufficiency. Pulses will not be affected in clients with venous insufficiency.

  3. A brown pigmented area with normal pulses.
    • Rationale:

      This answer is correct as venous stasis ulcers are known for having a brownish discoloration, irregular borders, and associated discolored drainage.

  4. A cold, hairless foot.
    • Rationale:

      This answer choice is not correct as a cold and hairless foot is associated with arterial insufficiency. Arterial insufficiency causes poor peripheral perfusion which causes extremities to be cool to touch and a lack of hair growth.

Overview

Venous stasis ulcers result from long standing chronic venous insufficiency. Venous insufficiency causes poor circulation in the form of blood return back up to the heart from the extremities. As blood pools in the extremities, ulcers may result. These types of ulcers usually have a brownish discoloration as well as drainage and irregular borders.

Explanation

Learning Outcomes

The focus of this question is asking the nurse to determine the best description of the appearance of a venous stasis ulcer. Venous stasis ulcers result from the stasis of blood pooling in the extremities and usually have a brownish discoloration with drainage around the ulcer. Pulses will not be affected in clients with isolated venous insufficiency.

Test Taking Tip

Peripheral vascular disease is an umbrella term used to describe chronic venous insufficiency and arterial insufficiency which have very different manifestations.

Video Rationale