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

Pedal pulses are +1 bilaterally

Complaints of burning pain during the night

Tissue that is blackened on the great toe

Answer and Explanation

The Correct Answer is C

Choice A rationale

Complaints of muscle cramps with exercise. While muscle cramps with exercise can be a symptom of peripheral arterial disease (PAD), they are more commonly associated with the earlier stages of the disease, known as intermittent claudication.

Choice B rationale

Pedal pulses are +1 bilaterally. Reduced or absent pedal pulses can be a sign of PAD, but a finding of +1 pedal pulses does not necessarily correlate with stage III of the disease.

Choice C rationale

Complaints of burning pain during the night. Stage III PAD, also known as critical limb ischemia, is characterized by more severe symptoms, including discomfort or pain in the feet or toes, even while at rest. Symptoms tend to worsen at night.

Choice D rationale

Tissue that is blackened on the great toe. This is a sign of gangrene, which is a severe and potentially life-threatening complication of PAD2. However, it is not a typical finding in stage III PAD, and would more likely be seen in the most advanced stage of the disease.

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Correct Answer is C

Explanation

Choice A rationale

While a past medical history of myocardial infarction does increase the risk of deep vein thrombosis (DVT), it is not the highest risk factor among the options provided. Other factors such as immobility, surgery, and certain medical conditions can pose a higher risk.

Choice B rationale

Postoperative patients, such as those who have had a laparoscopic knee replacement, are at an increased risk for DVT due to periods of immobility and changes in blood flow and clotting.

However, the risk is not as high as in patients who have undergone major open abdominal surgery.

Choice C rationale

Patients who have undergone major open abdominal surgery are at the highest risk for the development of DVT among the options provided. The surgery itself, along with the postoperative period of immobility, significantly increases the risk of DVT34567.

Choice D rationale

While peptic ulcers can be associated with certain risk factors for DVT, such as age and immobility due to pain, they do not pose as high a risk as major open abdominal surgery.

A. Changes to achieve low HDL and high LDL levels. B. Self-monitoring of blood glucose. C. Maintenance of a healthy weight. D. Utilizing carbohydrate counting to match insulin intake.

Correct Answer is C

Explanation

Choice A rationale

Changes to achieve low HDL and high LDL levels are not recommended. In fact, the opposite is desired. High levels of HDL (good cholesterol) and low levels of LDL (bad cholesterol) are beneficial for overall health and can help prevent cardiovascular complications associated with diabetes.

Choice B rationale

Self-monitoring of blood glucose is important for managing diabetes, but a fasting plasma glucose level of 118 mg/dL does not necessarily indicate the need for regular self-monitoring. This level is slightly elevated and may indicate prediabetes, but further testing would be needed for a definitive diagnosis.

Choice C rationale

Maintenance of a healthy weight is beneficial for everyone, but it’s particularly important for individuals with prediabetes or diabetes. Achieving and maintaining a healthy weight can help regulate blood glucose levels and prevent or delay the progression of prediabetes to diabetes.

Choice D rationale

Utilizing carbohydrate counting to match insulin intake is a strategy used in the management of diabetes. However, a fasting plasma glucose level of 118 mg/dL, while slightly elevated, does not necessarily indicate the need for insulin therapy or carbohydrate counting. Further testing would be needed to confirm a diagnosis of diabetes.

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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?

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for the following four clients on the nursing unit. Which client is at the highest risk for the development of deep vein thrombosis?

Correct Answer is C

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

A client undergoing screening for diabetes has a fasting plasma glucose level of 118 mg/dL. What should the nurse plan to educate the client about?

Correct Answer is C

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

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