The nurse is providing care for a client recently diagnosed with peripheral arterial occlusive disease (PAD). What assessment finding is most consistent with this diagnosis?
Visible clubbing of the fingers and toes
Unequal peripheral pulses between extremities
Reddened extremities with muscle atrophy
Loss of hair on the distal extremities
The Correct Answer is D
A. Visible clubbing of the fingers and toes
Clubbing is a condition characterized by changes in the shape and appearance of the fingers and toes. It involves enlargement of the fingertips and the nails becoming curved and rounded. Clubbing is not typically associated with peripheral arterial occlusive disease (PAD). It is more commonly seen in conditions such as chronic respiratory or cardiovascular diseases.
B. Unequal peripheral pulses between extremities
Unequal peripheral pulses can be indicative of vascular abnormalities. However, in PAD, the characteristic finding is diminished or absent pulses rather than unequal pulses between extremities. Other conditions, such as arterial embolism or thrombosis, may present with unequal pulses.
C. Reddened extremities with muscle atrophy
Reddened extremities and muscle atrophy are not typical findings in PAD. These symptoms are more characteristic of conditions associated with chronic inflammation or compromised venous circulation, such as chronic venous insufficiency or venous stasis.
D. Loss of hair on the distal extremities
Loss of hair on the distal extremities, particularly on the lower legs and feet, is a common finding in PAD. It results from reduced blood flow and oxygen supply to the hair follicles in the affected areas.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["125"]
Explanation
To calculate the amount of mL that the client should receive, we need to use the formula:
mL = (g * 5 mL) / mg
where g is the ordered dose of the medication, mg is the concentration of the medication, and mL is the volume of the solution.
Plugging in the given values, we get:
mL = (4 g * 5 mL) / 160 mg
Simplifying, we get:
mL = 0.125 g/mL
Multiplying by 1000 to convert grams to milligrams, we get:
mL = 125 mg/mL
Therefore, the client should receive 125 mL of the solution.
Correct Answer is ["B","C","D","E"]
Explanation
A. Administer antibiotics
Administering antibiotics is not a direct intervention for preventing atelectasis. Antibiotics are typically prescribed to treat bacterial infections, and atelectasis is more related to lung collapse or incomplete lung expansion.
B. Encourage increased oral fluid intake
Adequate hydration is important for maintaining the moisture of respiratory secretions. This helps prevent mucus from becoming thick and sticky, making it easier for the patient to cough and clear the airways.
C. Early mobilization after surgery
Early mobilization, including activities such as getting out of bed and walking, helps improve lung expansion. It promotes better ventilation and prevents areas of the lungs from collapsing, reducing the risk of atelectasis.
D. Frequent turning of the patient
Turning the patient regularly is crucial for preventing pooling of respiratory secretions in dependent areas of the lungs. By changing the patient's position, nurses can facilitate drainage and ventilation throughout the lungs, minimizing the risk of atelectasis.
E. Use of incentive spirometry
Incentive spirometry is a breathing exercise device that encourages the patient to take slow, deep breaths. This helps expand the lungs and prevents atelectasis by maintaining lung volume and promoting alveolar recruitment.
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