The nurse is assessing a client who reports pain to the left lower extremity, especially while ambulating. The discomfort is relieved with rest. Assessment findings confirm left lower leg mottling and hairlessness. Which health problem will the nurse most likely include in the planning of the client's care?
Peripheral vascular disease
Coronary artery disease
Right sided heart failure
Arterial embolism
The Correct Answer is A
A. Peripheral vascular disease: Intermittent claudication, or pain that occurs during ambulation and is relieved by rest, is a hallmark of arterial insufficiency. Mottling and hairlessness are objective signs of chronic tissue ischemia due to reduced peripheral blood flow. These findings indicate that the arterial supply is failing to meet the metabolic demands of the lower extremity.
B. Coronary artery disease: This condition involves the narrowing of the arteries supplying the heart muscle, typically presenting as chest pain or angina. While it shares the same underlying atherosclerotic process as peripheral vascular disease, it does not directly cause leg mottling or hairlessness. The client’s specific symptoms are localized to the peripheral rather than the cardiac circulation.
C. Right sided heart failure: Right-sided failure primarily manifests as systemic venous congestion, leading to jugular venous distention and dependent edema. It does not typically cause intermittent claudication or the skin changes associated with arterial deprivation. While it affects the lower extremities, it presents with swelling rather than mottling and hair loss.
D. Arterial embolism: An acute embolism usually presents with the "six Ps," including sudden, severe pain, pulselessness, and pallor. The client's report of intermittent pain relieved by rest suggests a chronic, progressive narrowing rather than an acute, total occlusion. An embolism is an emergency that would not typically be relieved simply by resting.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
A. Distended jugular veins: Right-sided failure increases pressure in the right atrium and vena cava, leading to visible engorgement of the internal jugular veins. This finding reflects the retrograde backup of blood into the systemic venous system. It is a primary clinical indicator of elevated central venous pressure.
B. Weight gain: Rapid increase in body mass in heart failure patients is almost exclusively due to the retention of sodium and water. As the kidneys perceive low perfusion, the renin-angiotensin-aldosterone system triggers fluid volume expansion. This leads to the systemic accumulation of fluid characteristic of right-sided dysfunction.
C. Orthopnea: This symptom involves difficulty breathing while lying flat and is a classic sign of left-sided heart failure and pulmonary congestion. It occurs when fluid from the lower extremities redistributes to the lungs in a recumbent position. Right-sided failure alone does not typically cause this pulmonary-specific symptom.
D. Peripheral edema: Increased systemic venous pressure causes fluid to leak from the capillaries into the interstitial spaces of the lower extremities. This presents as swelling in the feet, ankles, and pretibial areas, often worsening as the day progresses. It is a hallmark sign of right-heart pump failure.
E. Crackles the lungs: Adventitious lung sounds like crackles indicate fluid in the alveoli, which is a manifestation of pulmonary edema. Pulmonary edema is caused by the failure of the left ventricle to move blood into the systemic circulation. It is not a direct finding of isolated right-sided heart failure.
Correct Answer is A
Explanation
A. "I will take another tablet every 5 minutes if the pain continues up to 3 doses and then I will call 911 if the chest pain does not go away.": This statement reflects the standard emergency protocol for managing acute anginal episodes at home. It ensures the patient receives maximum pharmacological benefit while establishing a clear timeline for seeking emergency medical intervention. Adhering to this 15-minute window is crucial for preventing extensive myocardial damage.
B. "I take this medication at bedtime everything.": Nitroglycerin tablets are intended for the PRN treatment of acute chest pain, not as a scheduled nightly medication. Taking the drug without active symptoms can lead to significant hypotension and unnecessary side effects like headaches. Bedtime dosing is not the indicated use for sublingual nitroglycerin therapy.
C. "I will swallow the tablet whole with grapefruit juice.": Sublingual nitroglycerin must be dissolved under the tongue to bypass first-pass hepatic metabolism and enter the bloodstream rapidly. Swallowing the tablet significantly reduces its effectiveness and delays the onset of action during an ischemic event. Furthermore, grapefruit juice can interact with various cardiovascular medications and should be avoided.
D. "I take three tablets all at one time if I have chest pain.": Taking multiple doses simultaneously can cause a profound and dangerous drop in blood pressure. The doses must be spaced 5 minutes apart to allow the nurse or patient to evaluate the effectiveness and monitor for adverse effects. Proper titration is essential for safe and effective vasodilation.
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