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

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A reason: A healed, painful area on the spine is unrelated to peripheral artery disease, which affects limb circulation. It may indicate a separate issue but is not a priority safety concern for this condition, making it less urgent to report compared to balance issues.

Choice B reason: Needing to walk slowly due to frequent loss of balance is a safety concern in peripheral artery disease, as it suggests neuropathy or severe ischemia, increasing fall risk. This requires immediate provider attention to prevent injury, making it the correct statement to report.

Choice C reason: Feeling sad about not keeping up with grandchildren reflects emotional impact but not an immediate safety concern in peripheral artery disease. Balance issues pose a greater risk, making this less urgent to report, as it does not indicate physical harm.

Choice D reason: Avoiding going out due to leg pain is expected in peripheral artery disease (claudication) but is not an immediate safety concern like balance loss. It requires management but not urgent reporting, making this incorrect compared to the fall risk indicated by balance issues.

A. I will need to massage my legs frequently to prevent a buildup of fluid B. I will inspect my legs every day for changes in color, size, and temperature C. I will decrease my activity to prevent added stress on my legs D. I will keep my legs in a dependent position

Correct Answer is B

Explanation

Choice A reason: Massaging legs in peripheral venous disease can dislodge clots, increasing embolism risk. Proper management includes elevation and compression, not massage, to reduce edema. This statement is incorrect, indicating a need for further teaching to prevent dangerous practices in managing venous disease symptoms.

Choice B reason: Inspecting legs daily for changes in color, size, and temperature reflects understanding of peripheral venous disease management. Monitoring detects complications like thrombosis or infection early, allowing timely intervention. This is a correct practice, as it supports proactive symptom management and prevents worsening of the condition.

Choice C reason: Decreasing activity worsens venous stasis in peripheral venous disease, as movement promotes venous return. Exercise, like walking, is recommended to reduce edema and thrombosis risk. This statement is incorrect, indicating a need for teaching to emphasize the importance of activity in symptom management.

Choice D reason: Keeping legs in a dependent position increases edema in peripheral venous disease by promoting blood pooling. Elevation reduces venous pressure and swelling. This statement is incorrect, requiring further teaching to clarify that leg elevation, not dependency, is essential for managing venous disease symptoms.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data on a client who has peripheral artery disease for potential safety concerns. Which of the following client statements should the nurse report to the provider?

Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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