A nurse is caring for a client who has musculoskeletal injuries to the left lower extremity. Which of the following assessments should the nurse perform to evaluate the neurovascular status of the client's extremity?

Check skin temperature distal to the injury with the dorsum of the hand.

Press the heel of the foot to determine capillary refill.

Monitor sensation by palpating the pad of the great toe with a blunt needle.

Compare the color of the skin proximal to the injury with the other extremity.

Answer and Explanation

The Correct Answer is A

A. Check skin temperature distal to the injury with the dorsum of the hand.: Assessing skin temperature distal to the injury is an important part of evaluating neurovascular status. It helps to identify any changes in circulation or potential complications like ischemia. The dorsum of the hand is commonly used as it provides a good comparison to the temperature of the affected extremity.

B. Press the heel of the foot to determine capillary refill.: While capillary refill is an important assessment, it is usually measured by pressing the nail beds or pads of the fingers and toes, not by pressing the heel. This method does not provide a reliable indication of neurovascular status.

C. Monitor sensation by palpating the pad of the great toe with a blunt needle.: While assessing sensation is important, it is typically done using a light touch or pinprick, rather than palpating with a blunt needle. The use of a needle is not standard practice for this type of assessment.

D. Compare the color of the skin proximal to the injury with the other extremity.: Comparing the skin color distal to the injury with the unaffected extremity is more relevant for evaluating neurovascular status. Proximal comparison is less effective in assessing circulation and potential issues related to the injury.

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Correct Answer is B

Explanation

A. Antimicrobial medication can decrease the severity of symptoms.: Antiviral medications, rather than antimicrobial ones, are used to reduce the severity and duration of herpes zoster (shingles). They work best when started within 72 hours of the rash appearing.

B. Postherpetic nerve pain can occur in older adult clients.: Postherpetic neuralgia (PHN) is a common complication of herpes zoster, especially in older adults. It is characterized by persistent pain in the area where the shingles rash occurred.

C. Lesions often occur inside the oral cavity of clients who have this infection.: Herpes zoster typically causes a painful rash that appears on one side of the body, often in a band or strip, rather than inside the oral cavity. Oral lesions are more characteristic of herpes simplex virus infections.

D. Cellulitis is a common manifestation in clients who have this infection.: Cellulitis is not a typical manifestation of herpes zoster. Herpes zoster is characterized by a vesicular rash and pain along a dermatomal distribution, not by cellulitis.

A. Restrict fluids to decrease lower extremity swelling. B. Limit exercise to 10 min twice a day. C. Use ice packs to decrease leg pain. D. Sit with legs dependent when having pain.

Correct Answer is D

Explanation

A) Restrict fluids to decrease lower extremity swelling: Restricting fluids is generally not recommended for managing peripheral arterial disease (PAD). Fluid restriction may not address the underlying vascular issues causing swelling and might lead to dehydration. The focus should be on improving circulation and managing PAD symptoms.

B) Limit exercise to 10 min twice a day: Exercise is a critical component of managing PAD, and limiting it to only 10 minutes twice a day may not provide sufficient benefit. Patients with PAD are often encouraged to engage in regular, supervised exercise programs to improve circulation and reduce symptoms.

C) Use ice packs to decrease leg pain: Using ice packs is not advisable for PAD. Cold can constrict blood vessels and potentially worsen symptoms. Warmth or gentle heat may be more beneficial for improving circulation and relieving pain.

D) Sit with legs dependent when having pain: Sitting with the legs dependent (hanging down) can help alleviate pain associated with PAD. This position helps increase blood flow to the lower extremities and can reduce pain caused by intermittent claudication, a common symptom of PAD.

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