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 D
Explanation
A. This is a normal platelet count and is not directly related to DVT.
B. This is a normal PT result and does not indicate a clotting disorder that would predispose the client to DVT.
C. This is a normal aPTT result and does not indicate a clotting disorder that would predispose the client to DVT.
D. D-dimer is a marker of blood clot breakdown. An elevated D-dimer level suggests the presence of a blood clot, making it the most concerning laboratory result in this case.
Correct Answer is A
Explanation
This is the expected peak time for regular insulin. After administration, the insulin will generally reach its maximum effectiveness in lowering blood glucose within this timeframe, making it essential for the client to monitor their blood sugar levels accordingly.
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