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 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.
Correct Answer is C
Explanation
C. The DASH eating plan emphasizes consumption of fruits, vegetables, low-fat dairy products, whole grains, lean proteins, and limited amounts of saturated fats, cholesterol, and sodium. Therefore, enjoying fat-free yogurt as an occasional snack food aligns with the principles of the DASH eating plan.
A. is a good practice for food safety but does not specifically indicate adherence to the DASH eating plan. The DASH plan encourages consumption of fruits and vegetables but does not require meticulous cleaning or peeling.
B. may be suitable for individuals with lactose intolerance but is not a specific requirement of the DASH eating plan. The DASH plan recommends low-fat or fat-free dairy products but does not specify lactose-free products.
D. The DASH plan encourages consumption of whole grains as part of a balanced diet and recommends incorporating whole grains such as whole wheat, brown rice, and oats.
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