A home health nurse is seeing an elderly male client for the first time. During the physical assessment of the skin on the lower legs the skin is pale and cool to touch. The nurse notes small circular ulcers on the soles of his feet. From these findings, the nurse knows that the client has a problem with circulation. Which of the circulation condition does the nurse suspect?
Necrotic wound
Trauma
Venous insufficiency
Arterial insufficiency
The Correct Answer is D
The findings of pale and cool skin on the lower legs, along with small circular ulcers on the soles of the feet, are indicative of arterial insufficiency. Arterial insufficiency occurs when there is a decreased blood flow to the extremities, often due to conditions such as atherosclerosis or peripheral arterial disease. This reduced blood flow can result in pale and cool skin, as well as the development of ulcers, which are typically round and have well-defined borders. It is essential to assess and manage arterial insufficiency promptly to prevent complications like tissue necrosis and gangrene.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Venous thromboembolism (VTE) - While VTE can cause leg pain and swelling, the presence of fever, chills, and localized trauma history in this scenario points more toward cellulitis.
B. Cellulitis
The client's symptoms, including pain, swelling, fever, chills, and sweating, are indicative of cellulitis, which is a bacterial skin infection. The history of trauma to the leg (hitting the leg on the car door) could have introduced bacteria into the skin, leading to the infection. The client's diabetes mellitus type 2 also increases the risk of developing skin infections due to impaired immune function and circulation. Cellulitis often presents with localized pain, swelling, warmth, redness, and systemic symptoms like fever and chills. Immediate medical evaluation and appropriate antibiotic treatment are necessary for cellulitis.
C. Arterial insufficiency - Arterial insufficiency typically presents with symptoms like intermittent claudication, rest pain, and non-healing wounds due to poor circulation. The symptoms described in the scenario are more consistent with an acute infection (cellulitis) rather than chronic arterial insufficiency.
D. Thrombocytopenia - Thrombocytopenia is a condition characterized by low platelet count and does not directly cause localized pain, swelling, and redness in the leg as described in the scenario.
Correct Answer is D
Explanation
A. "I will reduce my intake of sodium." - This statement is correct. High sodium intake can lead to increased calcium excretion through the urine, which can weaken bones. Reducing sodium intake can help prevent osteoporosis.
B. "I will limit my intake of soft drinks." - This statement is correct. Soft drinks, especially cola beverages, contain phosphoric acid, which can leach calcium from bones, leading to decreased bone density. Limiting soft drink consumption is advisable for bone health.
C. "I will decrease my intake of caffeine." - This statement is correct. Excessive caffeine consumption can interfere with calcium absorption and increase calcium excretion. It is advisable to limit caffeine intake to prevent osteoporosis.
D. "I will reduce my intake of vitamin K-rich foods." - This statement is incorrect. Vitamin K is essential for bone health as it helps in bone mineralization and reduces the risk of fractures. Foods rich in vitamin K, such as leafy green vegetables, are beneficial for bone health and should not be reduced unless there are specific medical reasons to do so.
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