A nurse is assessing a client who has peripheral artery disease. Which of the following findings should the nurse recognize as requiring immediate intervention?

Lower extremities edematous with decreased pulses and cool to the touch

Pain, pallor, and paresthesia in the foot

Murmur auscultated at the left 5th midclavicular line, slight dyspnea, and lower extremity edema

Presence of an open wound near the ankle with serous drainage and pruritus

Answer and Explanation

The Correct Answer is B

A. Lower extremities edematous with decreased pulses and cool to the touch While this finding suggests impaired circulation associated with peripheral artery disease, it does not indicate an immediate need for intervention. However, it requires timely assessment and intervention to prevent further complications.

B. Pain, pallor, and paresthesia in the foot This finding indicates critical limb ischemia, which is a severe complication of peripheral artery disease requiring immediate intervention. Pain, pallor (pale color), and paresthesia (abnormal sensations like tingling or numbness) suggest inadequate blood flow to the affected limb, putting the client at risk for tissue damage and limb loss if not promptly addressed.

C. Murmur auscultated at the left 5th midclavicular line, slight dyspnea, and lower extremity edema These findings are suggestive of cardiac issues such as heart failure rather than immediate complications of peripheral artery disease. While they require attention, they do not signify an urgent need for intervention specific to peripheral artery disease.

D. Presence of an open wound near the ankle with serous drainage and pruritus While an open wound warrants assessment and appropriate wound care, it does not indicate an immediate need for intervention unless there are signs of infection or severe tissue damage. In this scenario, the presentation of pain, pallor, and paresthesia indicates a more urgent need for intervention to prevent tissue necrosis and limb loss.

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Correct Answer is B

Explanation

B. Provide opportunities for education and continually evaluate the client's preferences and goals for care:
This is the most effective intervention. Providing education and involving the client (to the extent possible) in decision-making helps reduce anxiety and build trust. Even though individuals with Alzheimer's disease may have limited memory and cognitive abilities, ongoing communication about the transition and individualized care plans can help ease the process. Additionally, continuously evaluating the client's preferences and goals ensures that the care plan remains person-centered and aligns with their needs, helping to minimize relocation stress.

A. Comply with compression therapy. B. Monitor wounds on lower extremities. C. Take antiplatelet medications as ordered. D. Monitor for gradual onset of symptoms

Correct Answer is D

Explanation

A. Comply with compression therapy:

Compression therapy typically refers to the use of compression garments or devices to improve circulation and reduce swelling in the extremities, particularly in conditions such as venous insufficiency or deep vein thrombosis.

While compression therapy may be beneficial for certain circulatory disorders, it is not a standard treatment for cardiac tamponade.

Cardiac tamponade is a medical emergency characterized by the accumulation of fluid in the pericardial sac, leading to increased pressure on the heart and impaired cardiac function.

Treatment for cardiac tamponade involves prompt recognition and intervention to relieve the pressure on the heart, such as pericardiocentesis or surgical drainage of the pericardial effusion.

B. Monitor wounds on lower extremities:

Monitoring wounds on the lower extremities is essential for assessing healing, preventing complications such as infection, and promoting overall wound care.

However, monitoring wounds on the lower extremities is not directly related to the management or monitoring of cardiac tamponade.

In cardiac tamponade, the focus of monitoring is on assessing signs and symptoms of cardiac compromise, such as hypotension, tachycardia, dyspnea, and pulsus paradoxus, rather than wound care.

C. Take antiplatelet medications as ordered:

Antiplatelet medications, such as aspirin or clopidogrel, are commonly prescribed to prevent platelet aggregation and reduce the risk of thrombotic events, particularly in patients with cardiovascular disease or a history of myocardial infarction or stroke.

While antiplatelet medications may be part of the long-term management of certain cardiac conditions, they are not specific to the treatment or monitoring of cardiac tamponade.

The primary treatment for cardiac tamponade involves interventions to relieve the pressure on the heart and restore cardiac function, such as pericardiocentesis or surgical drainage of the pericardial effusion.

D. Monitor for gradual onset of symptoms:

Phase II of cardiac tamponade is characterized by a gradual onset of symptoms as the pressure within the pericardial sac increases, leading to impaired cardiac filling and decreased cardiac output.

Symptoms may include dyspnea, fatigue, orthopnea, tachycardia, and chest discomfort, which may develop gradually over time.

Early recognition of symptoms is crucial for prompt diagnosis and intervention to prevent further deterioration and improve outcomes in patients with cardiac tamponade.

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A nurse is assessing a client who has peripheral artery disease. Which of the following findings should the nurse recognize as requiring immediate intervention?

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