During the physical assessment of the peripheral vascular system, a client's foot is pale when elevated and dark red when in the dependent position. The nurse is concerned that this client is at risk for developing:

Venous insufficiency ulcers

Arterial insufficiency ulcers

Neuropathic ulcers

Deep vein thrombosis

Answer and Explanation

The Correct Answer is B

A. Venous insufficiency ulcers: Typically present with dark discoloration and edema, but not specifically with changes in color with elevation and dependency.

B. Arterial insufficiency ulcers: Pale feet when elevated and dark red when dependent are classic signs of arterial insufficiency. These changes in color are due to poor blood flow.

C. Neuropathic ulcers: Usually associated with diabetes and often occur on pressure points, not typically related to color changes with elevation.

D. Deep vein thrombosis: While DVT can cause swelling and pain, it does not usually present with color changes that are dependent on the position of the foot.

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Correct Answer is B

Explanation

A. Systolic murmur: Systolic murmurs occur during systole and include conditions like aortic stenosis or mitral regurgitation.

B. Diastolic murmur: Aortic insufficiency/regurgitation occurs during diastole when the aortic valve fails to close properly, allowing blood to flow back into the left ventricle.

C. Absent murmur: Aortic insufficiency/regurgitation is not classified as absent; it is detectable with auscultation.

D. Very faint murmur: Although aortic regurgitation murmurs can vary in intensity, the classification pertains to the timing of the murmur, not its loudness.

A. I B. X C. II D. III

Correct Answer is A

Explanation

A. I: A grade I murmur is very faint and may not be heard immediately without careful listening. The description of a murmur heard immediately upon placing the stethoscope indicates it is a grade I.

B. X: There is no grade X in the standard grading scale for heart murmurs.

C. II: A grade II murmur is quiet but easily heard with a stethoscope and would generally be more audible than described.

D. III: A grade III murmur is moderately loud and would be heard without difficulty. The description suggests a quieter murmur.

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During the physical assessment of the peripheral vascular system, a client's foot is pale when elevated and dark red when in the dependent position. The nurse is concerned that this client is at risk for developing:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Aortic insufficiency/regurgitation murmur is classified as a:

Correct Answer is B

Explanation

During chest auscultation, the nurse hears a quiet murmur immediately upon placing the stethoscope on the client's chest. The nurse interprets this as which grade?

Correct Answer is A

Explanation

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