In assessing a client with skin ulcers on the lower extremity, which findings indicate that the ulcers are likely to be of venous, rather than arterial, origin?
Absent pedal pulses and shiny skin.
Irregular ulcer shapes and severe edema.
Hairless lower extremities and cool feet.
Black ulcers and dependent rubor.
The Correct Answer is B
B. Severe edema is a common finding in venous insufficiency and is often present in the lower extremities. Venous hypertension leads to fluid leakage from capillaries, resulting in edema, which contributes to the development of venous ulcers. Venous ulcers typically have irregular shapes with irregular wound margins and may appear shallow or superficial.
A. Absent pedal pulses suggest arterial insufficiency, as reduced blood flow compromises peripheral circulation. Shiny skin, known as "thinning of the skin," is a characteristic finding in arterial insufficiency due to chronic ischemia and tissue hypoxia.
C. Hair loss on the lower extremities is a common finding in arterial insufficiency due to decreased blood flow to the hair follicles.
D. Black ulcers (gangrene) are indicative of tissue necrosis resulting from severe arterial insufficiency and lack of oxygen supply to the tissues. Dependent rubor refers to redness of the lower extremities when the legs are in a dependent position.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
B. Redness, tenderness, and drainage around the catheter site are classic signs of an exit site infection in peritoneal dialysis. Exit site infections are a common complication of peritoneal dialysis and can lead to more serious complications, such as peritonitis, if not promptly treated. Preventing exit site infections through proper catheter care and hygiene is essential in peritoneal dialysis management.
A. While outflow obstruction can occur in peritoneal dialysis, it typically presents with symptoms such as poor drainage of dialysate fluid, abdominal discomfort, and a decrease in dialysis efficiency. The described findings of redness, tenderness, and drainage around the catheter site are more indicative of a localized issue rather than outflow obstruction.
C. Atelectasis refers to the collapse of a part or the entire lung. While it can occur in hospitalized patients, especially those with underlying respiratory conditions, the described findings are not indicative of atelectasis. Atelectasis typically presents with symptoms such as dyspnea, cough, and decreased breath sounds on auscultation.
D. Peritonitis is a severe complication of peritoneal dialysis characterized by inflammation and infection of the peritoneal lining. While redness, tenderness, and drainage around the catheter site may precede peritonitis, the focus of concern in this scenario is primarily on preventing exit site infection, which, if left untreated, can progress to peritonitis.
Correct Answer is B
Explanation
B. Acute pancreatitis is inflammation of the pancreas that can cause severe upper abdominal pain, which may radiate to the back, fever, and vomiting. Elevated serum amylase and lipase levels are characteristic laboratory findings in acute pancreatitis, indicating pancreatic injury or inflammation. The client's symptoms and laboratory results are consistent with acute pancreatitis.
A. Hepatorenal failure, also known as hepatorenal syndrome, is a serious complication of advanced liver disease where there is progressive renal failure in the setting of liver dysfunction. While hepatorenal syndrome can present with symptoms such as abdominal pain, fever, and vomiting, it is not typically associated with significantly elevated serum amylase and lipase levels.
C. Biliary duct obstruction occurs when there is a blockage in the bile ducts, leading to impaired flow of bile from the liver to the small intestine. While biliary duct obstruction can cause symptoms such as upper abdominal pain and vomiting, it is not typically associated with significantly elevated serum amylase and lipase levels.
D. While surgical site infection is a potential complication following cholecystectomy (gallbladder removal surgery), it typically presents with symptoms such as wound redness, swelling, warmth, and purulent drainage from the incision site.
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