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
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B"]
Explanation
A. Limited access to fresh fruits and vegetables can contribute to poor dietary habits, which are linked to obesity and diabetes. Communities with food deserts often have higher rates of diabetes due to reduced access to nutritious food, leading to diets high in processed and unhealthy foods.
B. Living in disadvantaged communities is associated with increased diabetes prevalence and complications. Factors such as lower socioeconomic status, limited access to healthcare, poor health education, and environmental stressors can exacerbate health issues, including diabetes.
C. Having adequate health insurance is generally correlated with better health outcomes, including access to preventive care, regular monitoring, and treatment for diabetes. It does not contribute to increased prevalence or complications; rather, it mitigates them.
D. While certain viral infections have been studied for their potential role in triggering autoimmune diabetes (such as Type 1 diabetes), viral infections themselves are not a social inequity and do not directly correlate with increased diabetes prevalence in the same way that socioeconomic factors do.
E. Autoimmune disorders can be associated with Type 1 diabetes and some cases of Type 2 diabetes; however, this option does not reflect a social inequity. Instead, autoimmune disorders are more related to individual health conditions and genetics.
Correct Answer is C
Explanation
A. While D5 0.45% NS contains dextrose, it is not suitable as an initial treatment in HHS because patients are often hyperglycemic. Starting with dextrose can worsen hyperglycemia.
B. Although providing oxygen may be appropriate if the client shows signs of respiratory distress or hypoxia, it is not the first-line treatment for HHS. The immediate priority is addressing dehydration and hyperglycemia.
C. The initial therapy for HHS involves administering IV fluids, typically starting with 0.9% saline (normal saline). This helps to rapidly rehydrate the client and dilute the high glucose levels in the blood. Correcting dehydration is critical in HHS management.
D. Glucagon is typically used to treat hypoglycemia, not hyperglycemia. In HHS, the patient is hyperglycemic, so administering glucagon would not be appropriate.
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