A nurse is collecting data on 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
Pain, pallor, and paresthesia in the foot
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
The Correct Answer is B
Choice A reason: An open wound with serous drainage and pruritus suggests infection or chronic venous insufficiency, requiring attention but not immediate intervention. Pain, pallor, and paresthesia indicate acute ischemia, a more urgent threat in peripheral artery disease, as it risks limb loss, making this a lower priority.
Choice B reason: Pain, pallor, and paresthesia are critical signs of acute limb ischemia in peripheral artery disease, indicating severe arterial occlusion. These “P’s” (part of the 6 P’s) signal tissue hypoxia, requiring immediate intervention to restore blood flow and prevent necrosis or amputation, making this the priority finding.
Choice C reason: Edema, decreased pulses, and cool extremities suggest chronic peripheral artery disease but are less acute than pain, pallor, and paresthesia, which indicate immediate ischemia. While concerning, these findings are more stable, requiring management but not urgent intervention compared to acute ischemic symptoms.
Choice D reason: A murmur, dyspnea, and edema suggest heart failure, not an immediate peripheral artery disease complication. These require evaluation but are less urgent than acute ischemia (pain, pallor, paresthesia), which risks limb loss, making this finding a lower priority for immediate intervention in this context.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Increasing dietary potassium intake enhances diuretic effectiveness, especially with potassium-losing diuretics, by maintaining electrolyte balance and supporting blood pressure reduction. Foods like bananas help, making this the correct recommendation to improve hypertension management in a 69-year-old patient.
Choice B reason: High-intensity exercise is not advised for a 69-year-old on diuretics, as it risks dehydration or orthostatic hypotension. Moderate exercise is safer, making this incorrect, as the nurse should recommend appropriate activity levels to support, not strain, cardiovascular health.
Choice C reason: A high-sodium diet counteracts diuretics by promoting fluid retention, raising blood pressure. A low-sodium diet enhances diuretic efficacy, making this incorrect, as the nurse should recommend sodium restriction to improve hypertension control and medication effectiveness.
Choice D reason: Limiting fluid intake to 500 mL daily risks dehydration in a patient on diuretics, worsening hypotension or renal function. Adequate hydration is needed, making this incorrect, as the nurse should encourage balanced fluid intake to support safe diuretic therapy.
Correct Answer is B
Explanation
Choice A reason: Calcium deficiency causes muscle cramps or tetany, not pain relieved by rest. Intermittent claudication, pain during walking that resolves with rest, is characteristic of peripheral arterial disease, not hypocalcemia. This condition does not affect vascular flow, making it an incorrect suspicion for this symptom.
Choice B reason: Peripheral vascular problems, specifically peripheral arterial disease, cause intermittent claudication, characterized by leg pain during walking due to reduced arterial blood flow. Pain resolves with rest as oxygen demand decreases. This matches the client’s symptoms, making it the most likely condition the nurse should suspect.
Choice C reason: Acute vessel obstruction causes sudden, severe pain not relieved by rest, often with pallor or pulselessness, unlike intermittent claudication. The client’s pain relief with rest suggests chronic arterial insufficiency, making acute obstruction less likely than peripheral vascular disease as the suspected condition.
Choice D reason: Diabetes mellitus contributes to peripheral vascular disease but is not the direct cause of claudication-like pain. Pain relieved by rest points to arterial insufficiency, not solely diabetes. Peripheral vascular problems better explain the symptoms, as diabetes is a risk factor, not the primary condition.
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