A nurse is assessing a client who has peripheral artery disease.
Which of the following findings should the nurse recognize as requiring immediate intervention?
Presence of an open wound near the ankle with serous drainage and pruritus.
Lower extremities edematous with decreased pulses and cool to the touch.
Murmur auscultated at the left 5th midclavicular line, slight dyspnea, and lower extremity edema.
Pain, pallor, and paresthesia in the foot.
The Correct Answer is D
Choice A rationale
An open wound near the ankle with serous drainage and pruritus is more characteristic of chronic venous insufficiency rather than an acute arterial crisis. Venous ulcers are typically shallow and moist, and while they require wound care and infection prevention, they do not represent an immediate threat to the limb. This finding indicates chronic disease progression but does not suggest the sudden loss of perfusion that would necessitate an emergency surgical or pharmacological intervention.
Choice B rationale
Lower extremity edema combined with decreased pulses and coolness is common in advanced peripheral artery disease due to chronic poor perfusion and potentially concurrent venous issues. While these findings are significant and require ongoing management, they are often the baseline status for a patient with long-standing PAD. They do not signal the acute, sudden change in status that defines a clinical emergency, unlike the signs of complete arterial occlusion or acute limb ischemia.
Choice C rationale
A murmur at the 5th midclavicular line suggests mitral valve regurgitation or stenosis, and the accompanying dyspnea and edema suggest left-sided heart failure. These are serious cardiovascular symptoms that require evaluation; however, they represent a systemic cardiac issue rather than a localized complication of peripheral artery disease. While the patient needs a cardiac workup, this finding is not the most immediate threat specifically related to the vascular health of the lower extremities in this context.
Choice D rationale
Pain, pallor, and paresthesia are three of the six Ps of acute arterial occlusion, which is a medical emergency. This suggests that blood flow to the distal extremity has been severely compromised or completely blocked, leading to tissue hypoxia. Without immediate intervention, such as heparinization or an emergency embolectomy, the patient is at extremely high risk for irreversible tissue necrosis, gangrene, and eventual limb amputation. This finding takes absolute priority over chronic or non-ischemic symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Ibuprofen is a nonsteroidal anti-inflammatory drug that is generally discouraged immediately following a myocardial infarction or coronary intervention. It can increase the risk of cardiovascular events, such as reinfarction or stroke, by interfering with the antiplatelet effects of aspirin. Additionally, it may cause sodium retention and increase blood pressure, which adds unnecessary strain on the healing cardiac muscle. Patients are instead educated to use acetaminophen for minor pain management to avoid these risks.
Choice B rationale
Warfarin is an anticoagulant that inhibits vitamin K-dependent clotting factors, typically used for atrial fibrillation or prosthetic heart valves. While it prevents systemic emboli, it is not the standard medication for maintaining stent patency after a percutaneous transluminal coronary intervention. The primary concern after stent placement is platelet aggregation on the foreign metal surface. Warfarin alone does not adequately inhibit the specific pathways of platelet activation required to prevent acute or subacute stent thrombosis.
Choice C rationale
Plavix, or clopidogrel, is a P2Y12 receptor antagonist that inhibits platelet aggregation. Following percutaneous transluminal coronary intervention, especially with stent placement, dual antiplatelet therapy is essential. It prevents the formation of thrombi on the stent surface while the vessel wall undergoes endothelialization. Patients must be educated on the importance of strict adherence to this regimen to prevent catastrophic stent thrombosis. Common side effects include an increased risk of bruising and minor bleeding episodes.
Choice D rationale
Heparin is an intravenous or subcutaneous anticoagulant used in the acute hospital setting to provide immediate anticoagulation by potentiating antithrombin III. It is frequently used during the actual percutaneous procedure to prevent clotting on catheters and wires. However, it is not a discharge medication because it requires frequent monitoring of the partial thromboplastin time and is not available in a practical oral form. Long-term outpatient management relies on oral antiplatelet agents rather than heparin therapy.
Correct Answer is A
Explanation
Choice A rationale
Morphine is the drug of choice after the initial phase of an MI to manage pain that is unresponsive to nitroglycerin. It acts as an opioid analgesic and provides significant peripheral vasodilation, which reduces both preload and afterload, thereby decreasing myocardial oxygen demand. Furthermore, morphine has a calming effect on the central nervous system, effectively reducing the intense anxiety and sympathetic nervous system activation that can further strain an injured heart during the recovery phase.
Choice B rationale
Aspirin is an antiplatelet medication that is administered immediately upon suspicion of a myocardial infarction to prevent the further growth of a coronary thrombus. It is considered part of the initial acute management phase rather than a medication used specifically for the ongoing management of pain and anxiety. While it is essential for long-term secondary prevention, its primary mechanism of action is hematological and does not provide any analgesic or sedative benefits for the patient.
Choice C rationale
Oxygen therapy is indicated in the early stages of a myocardial infarction if the patient's oxygen saturation falls below 90 percent or if they are in respiratory distress. The goal is to increase the oxygen supply to the ischemic myocardial tissue. However, oxygen is a gas used to support oxygenation and is not a pharmacological agent for pain relief or anxiety. Recent guidelines suggest avoiding routine supplemental oxygen in non-hypoxic patients as it may cause vasoconstriction.
Choice D rationale
Nitroglycerin is a potent vasodilator used in the initial acute phase to relieve chest pain by improving coronary artery blood flow and reducing myocardial workload. While it is excellent for managing ischemic pain, it does not address the psychological anxiety or the severe, persistent pain that often follows a major infarction. Once the initial vessel dilation is achieved, morphine is often required to manage the remaining discomfort and the patient's heightened emotional and physiological stress response.
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