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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Neutrophils are a type of white blood cell involved in the body's immune response, particularly in fighting bacterial infections. In the context of burns, especially full-thickness burns with purulent drainage, an elevated neutrophil count (neutrophilia) may indicate an ongoing infection. Burn wounds are susceptible to bacterial colonization and infection due to the loss of the skin's protective barrier.
B. Blood pH level refers to the acidity or alkalinity of the blood. While maintaining normal blood pH is crucial for overall health, changes in blood pH are not typically directly related to the presence of purulent drainage in burn wounds.
C. Serum albumin is a protein found in the blood that plays a role in maintaining osmotic pressure and transporting various substances, including drugs and hormones. Low serum albumin levels (hypoalbuminemia) can occur in individuals with severe burns due to increased protein loss through damaged skin and decreased protein synthesis. However, it is not directly related to evaluating purulent drainage from burn wounds.
D. Platelet count: Platelets are blood cells involved in clotting, which is essential for wound healing. While thrombocytopenia (low platelet count) can occur in individuals with severe burns,it is not directly related to assessing infection in burn wounds.

A. Blood pressure of 120/80 mm Hg. B. Oxygen saturation level of 99% C. Headache rated at 0 on 0 to 10 scale. D. Ambulates easily without vertigo

Correct Answer is D

Explanation

A. This assessment finding may be within the normal range for blood pressure, but it does not directly indicate the effectiveness of the antihistamine medication for Ménière's disease. Antihistamines are not typically prescribed to directly affect blood pressure.
B. While maintaining adequate oxygen saturation is important for overall health, this finding is not specific to the management of Ménière's disease with antihistamine medication. Antihistamines are not typically prescribed to directly affect oxygen saturation levels. Therefore, this finding may not directly indicate the effectiveness of the medication for Ménière's disease.
C. Headache rated at 0 on a 0 to 10 scale is not specific to vertigo.
D. Ambulating easily without vertigo is relevant for assessing the effectiveness of the antihistamine medication for Ménière's disease. Vertigo, characterized by a sensation of spinning or dizziness, is a hallmark symptom of Ménière's disease.

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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?

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Naxlex Comprehensive Predictor Exams

While caring for a client with full thickness burns covering 40% of the body, the nurse observes purulent drainage from the wounds. Before reporting this finding to the healthcare provider, the nurse should evaluate which laboratory value?

Correct Answer is A

Explanation

A client experiences residual effects following an acute attack of Ménière's disease and receives a new prescription for an antihistamine. Which assessment finding indicates that the medication is effective?

Correct Answer is D

Explanation

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