A patient at the clinic says, "I always walk after dinner, but lately my leg cramps and hurts after just a few minutes. The pain goes away after I stop walking, though." Which focused assessment would the nurse make?
Assess for unilateral swelling, redness, and tenderness of either leg.
Ask about any skin color changes that occur in response to cold.
Palpate for the presence of dorsalis pedis and posterior tibial pulses.
Look for the presence of tortuous veins bilaterally on the legs.
The Correct Answer is C
Choice A reason: Assessing for unilateral swelling, redness, and tenderness is important when evaluating for conditions such as deep vein thrombosis (DVT). However, this patient's symptoms of leg cramps and pain that subsides with rest are more indicative of peripheral artery disease (PAD) rather than DVT. Therefore, while this assessment is valuable in certain contexts, it is not the most relevant for this patient's symptoms.
Choice B reason: Asking about skin color changes that occur in response to cold can help identify conditions such as Raynaud's phenomenon, which causes extremities to change color in response to cold or stress. However, this patient's symptoms of intermittent leg cramps and pain with walking are more suggestive of PAD, making this question less relevant in this situation.
Choice C reason: Palpating for the presence of dorsalis pedis and posterior tibial pulses is the most appropriate focused assessment. This patient's symptoms of leg cramps and pain that resolve with rest suggest intermittent claudication, which is a hallmark of PAD. By palpating these pulses, the nurse can assess the adequacy of blood flow to the lower extremities, which is crucial in diagnosing PAD.
Choice D reason: Looking for the presence of tortuous veins bilaterally on the legs is important for identifying varicose veins, which are characterized by enlarged, twisted veins. While varicose veins can cause leg discomfort, they are not typically associated with the type of pain that subsides with rest. This patient's symptoms are more indicative of PAD, making this assessment less relevant.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","E","F"]
Explanation
Choice A reason: Monitoring for signs of dehydration is crucial because Mr. Carter's symptoms of nausea and vomiting can lead to fluid loss. Ensuring adequate hydration is essential for maintaining overall health and supporting liver function.
Choice B reason: Providing education about proper hand hygiene is important to prevent the transmission of hepatitis A, especially since Mr. Carter recently traveled to an area where he may have been exposed to the virus. Proper hand hygiene can help reduce the risk of spreading the infection to others.
Choice C reason: Encouraging a high-protein dietary intake is not appropriate in this case. While protein is important for liver repair, Mr. Carter's liver function is compromised, and a high-protein diet may increase the liver's workload. Instead, a balanced diet with adequate calories and nutrients is recommended.
Choice D reason: Administering intravenous antibiotics is not indicated for hepatitis A, as it is a viral infection and not bacterial. Antibiotics would not be effective in treating this condition.
Choice E reason: Advising rest and limiting physical activity is important to support recovery. Mr. Carter's symptoms of fatigue and jaundice indicate that his body needs time to heal. Resting helps conserve energy and allows the liver to recover.
Choice F reason: Educating the patient about the need for lifelong hepatitis A vaccination is crucial. Although hepatitis A does not typically cause chronic infection, vaccination can prevent future infections and protect against the virus.
Correct Answer is ["B","C","E","F"]
Explanation
Choice A reason: The patient is alert and oriented x4. This indicates that the patient is fully aware of their surroundings and does not require follow-up for this finding.
Choice B reason: The patient reports nausea. Nausea can be a symptom of many underlying conditions, including gastrointestinal issues or medication side effects, and requires follow-up to determine the cause and provide appropriate treatment.
Choice C reason: The abdomen is tender to palpation. Abdominal tenderness can indicate inflammation, infection, or other abdominal pathology, which requires follow-up to identify the underlying cause and provide appropriate management.
Choice D reason: The patient is 60 years old. This is a demographic detail and does not indicate a medical condition requiring follow-up.
Choice E reason: The patient has dark amber urine. Dark amber urine can be an indication of dehydration or other underlying conditions that require follow-up to identify and address the cause.
Choice F reason: The patient's oral temperature is 102.4°F. A fever indicates the presence of an infection or other health issue that needs to be investigated and managed.
Choice G reason: The patient is voiding without difficulty. This indicates that there are no issues with urinary function, so no follow-up is required for this finding.
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