A nurse is assessing a client with peripheral artery disease (PAD). The client states that walking five blocks is possible without pain.
What query asked next by the nurse will give the best information?
"Could you walk further than that a few months ago?".
"Do you walk mostly uphill, downhill, or on flat surfaces?".
"Have you ever considered swimming instead of walking?".
"How much pain medication do you take each day?"
The Correct Answer is A
Choice A rationale
This question directly assesses for intermittent claudication, a hallmark symptom of peripheral artery disease (PAD). A decrease in walking distance before the onset of pain (claudication) over time indicates a progressive worsening of the arterial stenosis. This is a critical piece of information for staging the disease and evaluating the effectiveness of treatment.
Choice B rationale
The type of terrain (uphill, downhill, flat) can influence the workload on the leg muscles and therefore affect the onset of pain. However, this is a secondary factor. The most important clinical indicator for the progression of PAD is a change in the pain-free walking distance over time, regardless of the terrain.
Choice C rationale
Suggesting swimming instead of walking is a recommendation for a different exercise modality, but it does not provide diagnostic information about the client's current condition. The purpose of the initial assessment is to gather objective data on the progression of the disease, not to provide alternative lifestyle recommendations at this stage.
Choice D rationale
Asking about pain medication usage is important for pain management, but it does not provide specific information about the severity or progression of the peripheral artery disease itself. The primary symptom of PAD is pain upon exertion, and the key assessment is to determine the distance a person can walk before experiencing this pain, as well as if that distance is changing. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Wearing comfy sweatpants and house shoes is generally not a barrier to proper foot care. In fact, wearing loose-fitting, comfortable clothing and footwear that does not restrict circulation is beneficial for clients with peripheral vascular disease (PVD). Tight clothing or shoes can impair blood flow, exacerbating the symptoms of PVD and increasing the risk of skin breakdown and ulceration.
Choice B rationale
Receiving energy assistance to keep the house warm is a positive factor for a client with PVD. Cold temperatures cause vasoconstriction, which further reduces blood flow to the extremities. Maintaining a warm environment helps promote vasodilation, improving circulation and reducing the risk of pain, tissue damage, and compromised wound healing.
Choice C rationale
Having plenty of lotion available is a supportive factor for proper foot care. Clients with PVD often have dry, cracked skin due to poor circulation. Using non-alcohol-based lotions can help maintain skin integrity, prevent fissures, and reduce the risk of infection. The daughter’s support facilitates adherence to this aspect of the foot care regimen.
Choice D rationale
Tremors or shaking hands, which indicate a lack of fine motor coordination, pose a significant barrier to proper foot care. This deficit makes it difficult to perform essential tasks such as meticulously inspecting the feet for cuts, blisters, or other injuries, clipping toenails correctly, and applying lotion without causing skin damage. This can lead to missed injuries and delayed treatment.
Correct Answer is ["A","C","D","E","F"]
Explanation
Choice A rationale
Warfarin is a vitamin K antagonist that inhibits the synthesis of vitamin K-dependent clotting factors II, VII, IX, and X. Clients must be instructed to maintain a consistent intake of vitamin K-rich foods, such as leafy green vegetables, to avoid fluctuations in warfarin's anticoagulant effect and to maintain a stable INR.
Choice B rationale
Warfarin therapy itself does not impose driving restrictions. The primary concern is the bleeding risk associated with the medication, which would not typically affect a person's ability to drive. Driving is not a discharge instruction required specifically because of the medication itself.
Choice C rationale
Regular laboratory monitoring of the International Normalized Ratio (INR) is essential to ensure the warfarin dosage is therapeutic and safe. The INR normal range is 0.8-1.2. The therapeutic range for warfarin is typically 2.0-3.0 for most indications. Clients need to understand the importance of these appointments.
Choice D rationale
Warfarin is highly protein-bound and metabolized by the cytochrome P450 enzyme system, making it susceptible to numerous drug-drug interactions. Educating the client about potential interactions with other medications, including over-the-counter drugs, is crucial to prevent either bleeding or clotting episodes.
Choice E rationale
A client's adherence to a medication regimen is significantly enhanced when they understand the purpose of the treatment. Explaining that warfarin prevents dangerous blood clots in conditions like atrial fibrillation or deep vein thrombosis helps the client appreciate the importance of consistent daily dosing.
Choice F rationale
Wearing a Medic Alert bracelet is a critical safety measure for clients on warfarin. In an emergency, this bracelet immediately informs healthcare providers that the person is on an anticoagulant, allowing them to make informed decisions about care and to recognize signs of potential bleeding complications.
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