The nurse is assessing a client with a presumptive diagnosis of peripheral arterial disease. The nurse obtains an Ankle-Brachial index of 0.89. Which intervention should the nurse take next?

Document the information as a normal ﬁnding

Prepare the client for an arterial bypass

Educate the client about the use of compression stocking

Anticipate a prescription for clopidogrel and simvastatin

Answer and Explanation

The Correct Answer is D

An ABI of 0.89 indicates a reduced blood ﬂow to the lower extremities, which is suggestive of peripheral arterial disease (PAD). In PAD, there is narrowing or blockage of the arteries that supply blood to the legs and feet. Medications like clopidogrel and simvastatin are commonly prescribed for individuals with PAD to manage the condition and reduce the risk of complications.

Here's an explanation of why the other options are not the most appropriate interventions:

Document the information as a normal ﬁnding: An ABI of 0.89 is not considered a normal ﬁnding. An ABI value below 0.9 is generally indicative of PAD or reduced blood ﬂow to the lower extremities.

Prepare the client for an arterial bypass: An ABI value of 0.89 alone does not warrant immediate preparation for an arterial bypass. Arterial bypass surgery is typically considered for severe cases of PAD with signiﬁcant symptoms that signiﬁcantly impact the client's quality of life and other conservative treatments have not been successful.

Educate the client about the use of compression stockings: While compression stockings may be a part of the overall management of PAD, the ABI result alone does not indicate an immediate need for education about compression stockings. Other interventions, such as medication management, lifestyle modiﬁcations, and possibly revascularization procedures, may be more appropriate based on the severity of the PAD.

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Correct Answer is ["A","C","D","E"]

Explanation

The questions related to the client's history that are most important to ask are:

How would you describe your symptoms?: This question is important to assess the client's current cardiac symptoms and determine the severity, duration, and nature of their symptoms. It helps the nurse to evaluate the client's cardiac status and determine appropriate interventions.

Are you allergic to any medications or foods?: This question is crucial to identify any potential allergies that could impact the client's cardiac care. It helps the nurse ensure that medications and interventions are safe for the client and prevent any adverse reactions.

How did your mother die?:This question is important to gather information about the client's family history of cardiac diseases and potential risk factors. Understanding the family history helps the nurse assess the client's genetic predisposition to cardiac conditions and plan appropriate interventions and screenings.

Have you had shortness of breath or weight gain? : This question is important to assess for symptoms of heart failure or fluid retention. Shortness of breath and weight gain can indicate fluid accumulation, which is a common symptom in cardiac conditions. It helps the nurse evaluate the client's cardiac function and determine the need for furtherinterventions or medication adjustments.

Let's review the other options and explain why they are not the most important questions to ask:

Do you have any children?: While family history is important, specifically asking about children is not as relevant to the client's current cardiac condition. The focus should be on the client's own symptoms, medical history, and family history of cardiac diseases.

A. The client reports a headache with pain at level 5 of 10 B. The client has epistaxis after blowing his nose several times C. The client has a urine output of 120 mL over a 4 hours D. The client has a new-onset blurry vision and facial asymmetry

Correct Answer is D

Explanation

Among the given findings, the most important finding to report to the health care provider in a client with a hypertensive emergency is the new-onset blurry vision and facial asymmetry. These symptoms may indicate that the client is experiencing a hypertensive crisis with potential complications such as hypertensive encephalopathy or stroke.

Blurred vision and facial asymmetry are concerning neurological symptoms that suggest possible damage to the blood vessels or organs in the brain. It is crucial to notify the health care provider immediately so that appropriate interventions can be initiated to address the underlying cause and prevent further complications.

While the other findings may also be associated with elevated blood pressure, the new-onset blurry vision and facial asymmetry indicate possible neurological involvement and require immediate attention. Headache, epistaxis (nosebleed), and decreased urine output may be significant symptoms, but the potential neurological implications make the new-onset blurry vision and facial asymmetry the priority for reporting.

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The nurse is assessing a client with a presumptive diagnosis of peripheral arterial disease. The nurse obtains an Ankle-Brachial index of 0.89. Which intervention should the nurse take next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is interviewing a client with a complex cardiac history. Which questions related to the client's history are most important to ask? Select all that apply.

Correct Answer is ["A","C","D","E"]

Explanation

The nurse is assessing a client with a hypertensive emergency. Which finding is most important to report to the health care provider?

Correct Answer is D

Explanation

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