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 D

Explanation

A. Smoking: Although smoking is a risk factor for cardiovascular diseases and can contribute to thrombosis, it is not the most immediate factor in the context of post-surgical immobility.

B. Hypertension: While hypertension is a significant cardiovascular risk factor, it is less directly related to deep vein thrombosis compared to immobility.

C. Obesity: Obesity can increase the risk of DVT, but immobility, especially after surgery, is a more direct and immediate contributing factor.

D. Immobility: Immobility is a critical factor in the development of deep vein thrombosis, particularly in postoperative clients who may be bedridden or have limited mobility.

A. Auscultate the anatomic area with a stethoscope. B. Use Doppler ultrasonography to locate the pulse. C. Ask another nurse to assess the pulse. D. Document absence of dorsalis pedis pulse.

Correct Answer is B

Explanation

A. Auscultating the area may not provide accurate information about the pulse if it is not palpable, though it can be part of the assessment if Doppler is unavailable.

B. Using Doppler ultrasonography is the most appropriate next step to accurately assess the pulse if it is not palpable, especially in older adults where pulses may be difficult to detect.

C. Asking another nurse to assess the pulse may not address the underlying issue of why the pulse is not palpable and does not provide additional information.

D. Documenting the absence of the dorsalis pedis pulse without further investigation could be premature, as Doppler ultrasonography should be used to confirm its absence.

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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

The nurse is planning care for a client recovering from orthopedic surgery. Interventions should be included to address which contributing factor to deep vein thrombosis development?

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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