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. This position can increase pressure on the surgical site and hinder blood flow.
B. This position can also increase pressure on the surgical site and may be uncomfortable for the client.
C. This position promotes venous return, reduces swelling, and minimizes pressure on the surgical site.
D. This position can increase pressure on the surgical site and may hinder blood flow.

A. prevents bleeding and covers the incision. B. decreases phantom limb pain. C. limits the formation of blood clots. D. shapes the soft tissue and minimizes edema.

Correct Answer is D

Explanation

A. While an elastic bandage can provide some compression to control bleeding, its primary purpose post-amputation is not to prevent bleeding but to support the healing process. It does help cover the incision, but this is not its main function in the context of shaping the stump.
B. Phantom limb pain is a common phenomenon after amputation, where the patient feels sensations in the amputated limb. Wrapping the stump may provide some psychological comfort, but the elastic bandage does not directly decrease phantom limb pain.
C. While adequate compression can help with circulation, the primary function of wrapping the stump is not to prevent blood clots. Preventing blood clots is more relevant to immobilization and other measures, particularly in the early postoperative period.
D. The elastic bandage helps to compress the soft tissue of the stump, promoting a well-shaped residual limb. This shaping is important for fitting prosthetics later and helps minimize edema (swelling) in the area post-surgery.

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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 D

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