The nurse is caring for a client with a diagnosis of chronic peripheral arterial disease. Which statement by the client warrants immediate intervention by the nurse?
"I noticed that the hair on my feet and on my legs, is gone."
"My legs were so cold I had to put a heating pad on them."
"My legs start to hurt when I walk to get my mail."
"My feet look reddish when I put them down."
The Correct Answer is B
A. Loss of hair on the lower extremities can be a common sign of chronic PAD, indicating reduced blood
flow. While it’s an important observation, it is not an immediate concern.
B. Cold legs can indicate poor blood flow, which is a significant concern in PAD. The use of a heating pad can pose a risk of burns due to impaired sensation, especially in clients with poor circulation. This statement warrants immediate intervention, as the nurse should educate the client against using heat sources that can cause injury and assess the client's circulation and potential complications.
C. This describes claudication, a common symptom of PAD, where pain occurs in the legs due to inadequate blood flow during physical activity. While it indicates worsening symptoms of PAD, it is not an immediate emergency.
D. Reddish discoloration (rubor) when the legs are dependent can indicate blood pooling due to decreased venous return or arterial insufficiency. While this observation is significant and requires monitoring, it is not as urgent as the concern related to using a heating pad.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C"]
Explanation
A. This statement is correct and crucial. Completing the full course of antibiotics is essential to ensure the infection is fully treated and to prevent antibiotic resistance.
B. Metronidazole can cause a disulfiram-like reaction (similar to what occurs with alcohol and disulfiram) if alcohol is consumed during treatment or shortly after. Symptoms can include flushing, nausea, vomiting, and palpitations.
C. Metronidazole can potentially reduce the effectiveness of hormonal contraceptives. Using a barrier method, like condoms, can help prevent unintended pregnancy during treatment.
D. This statement is not necessary. Metronidazole is not typically associated with crystalluria or the need to strain urine for crystal fragments. This instruction does not apply to this medication.
E. This statement is inaccurate. While metronidazole can cause darkening of the urine, it is not specifically known to change urine to pale yellow. Typically, discoloration could be more of a brown or dark color, and pale yellow is not a common effect of this medication.
Correct Answer is A
Explanation
A. This is correct because clopidogrel is a blood thinner, and a common side effect is bleeding, which can manifest as black or bloody stools.
B. While this is general advice for people taking certain medications, it's not specifically related to clopidogrel.
C. There are no specific dietary restrictions for clopidogrel, and it can be taken with or without food.
D. Clopidogrel is often prescribed with low-dose aspirin to further reduce the risk of blood clots. However, it's important to consult with a healthcare provider before taking any new medications, including aspirin, while on clopidogrel.
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