What nonpharmacologic comfort measures should the nurse include ...

[theo]

What nonpharmacologic comfort measures should the nurse include in the plan of care for a client with severe varicose veins? (Select all that apply.)
 
  a. Administering mild analgesics for pain
  b. Applying elastic compression stockings
  c. Elevating the legs when sitting or lying
  d. Reminding the client to do leg exercises
  e. Teaching the client about surgical options

Question 2

The nurse is assessing a client on admission to the hospital. The client's leg appears as shown below:
 
  What action by the nurse is best?
  a.
  Assess the client's ankle-brachial index.
  b.
  Elevate the client's leg above the heart.
  c.
  Obtain an ice pack to provide comfort.
  d.
  Prepare to teach about heparin sodium.

[kjohnson]

Answer to Question 1

ANS: B, C, D
The three E's of care for varicose veins include elastic compression hose, exercise, and elevation. Mild analgesics are not a nonpharmacologic measure. Teaching about surgical options is not a comfort measure.

Answer to Question 2

ANS: A
This client has dependent rubor, a classic finding in peripheral arterial disease. The nurse should measure the client's ankle-brachial index. Elevating the leg above the heart will further impede arterial blood flow. Ice will cause vasoconstriction, also impeding circulation and perhaps causing tissue injury. Heparin sodium is not the drug of choice for this condition.