The client's chart indicates the diagnosis of stage III peripheral arterial disease. Which nursing assessment finding correlates with this diagnosis?

Complaints of muscle cramps with exercise

Complaints of burning pain during the night

Pedal pulses are +1 bilaterally

Tissue that is blackened on the great toe

Answer and Explanation

The Correct Answer is B

A.   While claudication (muscle cramps with exercise) is common in earlier stages of PAD, it typically occurs in stage II. In stage III, pain often occurs at rest rather than with exertion.
B.   In stage III PAD, patients often report rest pain, which can manifest as burning pain in the legs or feet, particularly at night when lying down. This is a hallmark symptom of advanced PAD due to inadequate blood flow.
C.   While diminished pulses (like +1) can be found in PAD, this finding alone is not specific to stage III. In advanced stages, pulses may be even weaker or absent.
D.   Blackened tissue (necrosis or gangrene) indicates a more severe stage (stage IV) of PAD, where there is critical limb ischemia and tissue death due to a lack of blood flow. Stage III may involve severe pain but usually does not have necrosis.

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Correct Answer is C

Explanation

A. While positioning a patient prone can help with certain surgical recovery situations, it is not typically used immediately after an above-the-knee amputation. Additionally, elevating the arms may not provide any benefit and could cause discomfort.
B. This position can increase the risk of contractures in the residual limb, especially with an above-the- knee amputation. Keeping the stump flat may also lead to swelling and discomfort.
C. This position allows for proper elevation of the stump, which can help reduce swelling and promote healing. Supporting the stump on pillows prevents the risk of contractures and maintains the limb in a neutral position. It provides comfort and stability while facilitating blood flow.
D. While this position can help with venous return and reduce the risk of complications such as orthostatic hypotension, it is not specifically beneficial for an above-the-knee amputation recovery. It may not adequately address the need for proper stump support and elevation.

A. maintenance of a healthy weight B. use of low doses of insulin regular. C. oral hypoglycemic agents D. self-monitoring of blood glucose.

Correct Answer is A

Explanation

A. Teaching the client about maintaining a healthy weight is crucial, especially in preventing the progression from prediabetes to type 2 diabetes. Weight management through diet and exercise can significantly improve insulin sensitivity and glucose control.
B. At a fasting plasma glucose level of 120 mg/dL, the client is not typically at the stage where insulin therapy is necessary. Insulin is usually reserved for individuals with established diabetes, particularly if they are unable to achieve glycemic control through lifestyle changes or oral medications.
C. Similar to option B, the use of oral hypoglycemic agents is not indicated for someone with a fasting glucose of 120 mg/dL. This level suggests prediabetes, and the initial approach is generally focused on lifestyle changes rather than medication.
D. While self-monitoring of blood glucose is important for individuals with diabetes, it may not be the immediate focus for a client with a fasting plasma glucose level of 120 mg/dL unless the physician has indicated a diagnosis of diabetes or if the client has symptoms. In prediabetes, education around lifestyle modifications is typically prioritized.

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The client's chart indicates the diagnosis of stage III peripheral arterial disease. Which nursing assessment finding correlates with this diagnosis?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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