The nurse is caring for a patient with a diagnosis of chronic peripheral arterial disease. Which statement by the patient warrants immediate intervention by the nurse?
“My feet look reddish when I put them down.”.
“I noticed that the hair on my feet and 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.”.
The Correct Answer is C
Choice A rationale
Reddish feet when put down could be a sign of dependent rubor, a condition that occurs due to peripheral arterial disease (PAD). When the legs are in a dependent (downward) position, gravity aids in delivering blood to the area, causing a reddish color. However, this is a common symptom of PAD and does not require immediate intervention.
Choice B rationale
Loss of hair on the feet and legs is another symptom of PAD1. This happens because inadequate blood flow deprives the hair follicles of the nutrients they need to grow. While this symptom indicates worsening PAD, it does not warrant immediate intervention.
Choice C rationale
Applying a heating pad to cold legs could lead to burns because PAD can cause loss of sensation in the legs. This warrants immediate intervention to prevent injury.
Choice D rationale
Leg pain during walking, also known as claudication, is a common symptom of PAD1. This happens because the muscles are not getting enough oxygen due to reduced blood flow.
However, this symptom does not require immediate intervention but should be evaluated further.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
People with Type 1 diabetes have little or no insulin that can be released. This is because their pancreatic β-cells, which produce insulin, are destroyed by an autoimmune process. Without insulin, glucose cannot be taken up into cells to be used for energy. Oral antihyperglycemic agents work by increasing the release of insulin or increasing the body’s sensitivity to insulin, so they are not effective in Type 1 diabetes where there is an absolute insulin deficiency.
Choice B rationale
The cost of oral antihyperglycemic agents is not the primary reason they are not used in Type 1 diabetes. The main issue is the lack of insulin production, which these medications cannot address.
Choice C rationale
People with Type 1 diabetes do not typically have resistance to their endogenous insulin. Insulin resistance is more commonly associated with Type 2 diabetes.
Choice D rationale
While hypoglycemia can occur with the use of some antihyperglycemic agents, this is not the primary reason these medications are not used in Type 1 diabetes. The main issue is the absolute deficiency of insulin.
Correct Answer is C
Explanation
Wearing closed-toe shoes when walking can help protect the feet from injuries. However, it does not directly address the issue of numbness and reduced sensation due to severe peripheral neuropathy.
Choice B rationale
Soaking feet daily to remove pathogens can help maintain hygiene, but it does not directly address the issue of numbness and reduced sensation due to severe peripheral neuropathy.
Choice C rationale
Examining your feet daily is a crucial intervention for patients with severe peripheral neuropathy. Due to the numbness and reduced sensation, patients might not notice injuries or changes in their feet. Regular self-examination can help detect any abnormalities early, preventing further complications.
Choice D rationale
Using lotion on all areas of the feet for moisture can help prevent dryness and cracking of the skin, but it does not directly address the issue of numbness and reduced sensation due to severe peripheral neuropathy.
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