A nurse is caring for a client who has peripheral arterial disease (PAD). Which of the following symptoms should the nurse expect to find in the early stage of the disease?
Dependent rubor
Intermitent claudication
Foot ulcers
Rest pain
The Correct Answer is B
The correct answer is B
Choice B reason: Intermittent claudication
Intermittent claudication is a characteristic symptom of PAD in the early stage, due to the reduced blood flow to the muscles during exercise. It is a cramping pain in the legs that occurs with walking and is relieved by rest.
Choice A reason: Dependent rubor is a sign of PAD in the advanced stage, due to the impaired vasodilation and reactive hyperemia. It is a reddish color of the lower extremities that occurs when they are lowered and disappears when they are elevated.
Choice C reason: Foot ulcers are a complication of PAD in the late stage, due to the poor wound healing and tissue necrosis. They are usually located on the toes, heels, or pressure points.
Choice D reason: Rest pain is another sign of PAD in the late stage, due to the severe ischemia and nerve damage. It is a persistent pain in the feet or toes that occurs at night and is not relieved by rest.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Nitroglycerin is a vasodilator that relaxes smooth muscle in blood vessels and reduces myocardial oxygen demand. It is used to treat and prevent angina atacks. A common side effect of nitroglycerin is headache, which is caused by cerebral vasodilation. The nurse should advise the client to take a mild analgesic, such as acetaminophen, to relieve the headache. The headache usually subsides with continued use of nitroglycerin.
The other options are not correct because:
"Take only one dose of nitroglycerin to reduce the risk of getting a headache." This statement is incorrect because it may compromise the effectiveness of nitroglycerin in relieving angina. The client should follow the prescribed dosage and frequency of nitroglycerin, which is usually one tablet every 5 minutes for up to three doses, as needed for chest pain.
"There's nothing that can be done to relieve the headaches that nitroglycerin causes." This statement is incorrect because it is discouraging and dismissive of the client's concern. The nurse should acknowledge the client's
discomfort and offer suggestions for managing the side effect, such as taking a mild analgesic or lying down in a dark room.
"We will ask the provider to prescribe a different medication for you." This statement is incorrect because it implies that nitroglycerin is not suitable for the client and may cause unnecessary anxiety or confusion. The nurse should explain that nitroglycerin is an effective and safe medication for angina and that the headache is a common and transient side effect that can be managed with simple measures. The nurse should also inform the client that there are other forms of nitroglycerin, such as patches or sprays, that may have less headache-inducing effects. However, changing the medication or the route of administration should be done only after consulting with the provider.
Correct Answer is D
Explanation
Hemorrhagic stroke is a type of stroke that occurs when a blood vessel ruptures in the brain, causing bleeding and increased intracranial pressure. The client's symptoms of sudden, severe headache, vomiting, seizure, and
unresponsiveness are consistent with hemorrhagic stroke. The client's elevated blood pressure and temperature are also risk factors for hemorrhagic stroke.
Thrombotic stroke is a type of stroke that occurs when a blood clot forms in an artery that supplies blood to the brain, causing ischemia and tissue damage. The client's symptoms are not typical of thrombotic stroke, which usually has a gradual onset and affects one side of the body.
Transient ischemic atack (TIA) is a temporary interruption of blood flow to the brain, causing neurologic deficits that resolve within 24 hours. The client's symptoms are not indicative of TIA, which does not cause loss of consciousness or permanent brain damage.
Embolic stroke is a type of stroke that occurs when a blood clot or other debris travels from another part of the body to the brain, causing occlusion and ischemia. The client's symptoms are not characteristic of embolic stroke, which usually has a sudden onset and affects one side of the body.
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