The nurse is performing a physical assessment of a client. Which finding should the nurse recognize is a result of a compromised peripheral arterial circulation of the lower extremity?
Bronze pigmentation.
Lower leg edema.
Uneven hair distribution.
Bounding peripheral pulse.
The Correct Answer is C
A. Bronze pigmentation is not typically associated with compromised peripheral arterial circulation but may be seen in conditions like hemochromatosis.
B. Lower leg edema is more commonly associated with venous insufficiency rather than compromised arterial circulation.
C. Uneven hair distribution, such as decreased hair growth on the lower extremity, is indicative of compromised peripheral arterial circulation due to reduced blood flow to the area.
D. Bounding peripheral pulse is not typically associated with compromised peripheral arterial circulation but may indicate increased stroke volume or arterial stiffness.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Avoiding tight-fitting clothes can help reduce intra-abdominal pressure, which may contribute to GERD symptoms, but it is not the most crucial instruction.
B. Minimizing intake of spicy foods can help decrease gastric irritation and reflux symptoms, but it is not the most important instruction.
C. Beginning a smoking cessation program is important for overall health and may help reduce GERD symptoms, but it is not the most critical instruction for managing GERD.
D. Remaining upright following meals is essential to prevent gastric reflux by reducing pressure on the lower esophageal sphincter. This instruction helps minimize reflux episodes and should be emphasized to the client with GERD.
Correct Answer is B
Explanation
A. Administer IV fluid bolus as prescribed by the healthcare provider is not the priority unless there is evidence of hypovolemia or shock, which isn't indicated by the current vital signs alone.
B. Medicate for pain and monitor vital signs according to protocol is the most important intervention. The client's elevated heart rate, respiratory rate, and blood pressure are likely due to inadequate pain control following a thoracotomy, a major surgical procedure known for causing significant postoperative pain. Managing the pain is crucial because uncontrolled pain can lead to increased sympathetic nervous system activity, resulting in tachycardia, hypertension, and tachypnea. Addressing the pain effectively will help stabilize these vital signs.
C. Encourage the client to splint the incision with a pillow to cough and deep breathe is an important postoperative intervention to prevent complications such as atelectasis, but it should be done after pain is adequately controlled, as pain can inhibit the ability to deep breathe and cough effectively.
D. Apply oxygen at 10 L/minute via non-rebreather mask and monitor pulse oximeter may be necessary if there are signs of hypoxia. However, the vital sign changes here are more likely related to pain rather than respiratory distress, making pain management the immediate priority.
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