A nurse in a long-term care facility is caring for an 83-year-old woman who has a history of heart failure and peripheral arterial disease. At present the patient is unable to stand or ambulate
What does the nurse know the patient is at significant risk for?
A) Aoritis
B) Deep vein thrombosis
C) Thoracic aortic aneurysm
D) Raynaud's disease
Ans: B
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 peripheral arterial disease, and altered blood coagulation from heart failure. Option A is incorrect; the cause of aoritis is unknown but there is no direct connection to heart failure, peripheral arterial disease, or mobility issues. Option C is incorrect; the greatest risk factors for thoracic aortic aneurysm are atherosclerosis and hypertension; there is no direct connection to heart failure, peripheral arterial disease, or mobility issues.
Option D is incorrect; Raynaud's disease is a disorder that involves spasms of blood vessels and again there is no direct connection to heart failure, peripheral arterial disease, or mobility issues.
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