The nurse is performing an assessment on an adult. The adult's vital signs are normal, and capillary refill time is 5 seconds. What should the nurse do next?
Consider this a normal capillary refill time that requires no further assessment.
Consider this a delayed capillary refill time, and investigate further.
Ask the patient about a history of frostbite.
Suspect that the patient has venous insufficiency.
The Correct Answer is B
A. Capillary refill time greater than 2 seconds is abnormal and requires further assessment.
B. A capillary refill time of 5 seconds indicates delayed peripheral perfusion and warrants further investigation.
C. While frostbite can cause delayed refill, it is less likely than vascular insufficiency in this scenario.
D. Delayed capillary refill is more often associated with arterial, not venous, insufficiency.
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Related Questions
Correct Answer is {"dropdown-group-1":"A"}
Explanation
Claudication due to arterial abnormalities in
Rationale: Intermittent claudication is a hallmark symptom of peripheral arterial disease (PAD). It is characterized by muscle pain or cramping in the lower extremities, typically triggered by exercise and relieved by rest. The pain occurs due to ischemia, or reduced blood flow, resulting from partial arterial obstruction.
Correct Answer is B
Explanation
A. Capillary refill time greater than 2 seconds is abnormal and requires further assessment.
B. A capillary refill time of 5 seconds indicates delayed peripheral perfusion and warrants further investigation.
C. While frostbite can cause delayed refill, it is less likely than vascular insufficiency in this scenario.
D. Delayed capillary refill is more often associated with arterial, not venous, insufficiency.
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