The nurse refers an older adult client for further evaluation after the nurse assesses warm skin and brown pigmentation around the ankles. The nurse suspects which of the following?

Dependent edema

Stasis ulceration

Arterial occlusion

Venous insufficiency

Answer and Explanation

The Correct Answer is D

A. Dependent edema is characterized by swelling in the lower extremities due to gravity and may not always present with pigmentation changes.

B. Stasis ulceration involves ulcerative lesions typically occurring on the lower legs, often associated with venous insufficiency, but the pigmentation alone does not confirm ulceration.

C. Arterial occlusion typically presents with symptoms such as pain, pallor, and decreased pulses, not necessarily with warm skin and brown pigmentation.

D. Venous insufficiency is characterized by symptoms such as warm skin, brown pigmentation around the ankles (due to hemosiderin deposition from blood pooling), and swelling.

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Correct Answer is B

Explanation

A. Chest pain: This symptom is important but does not specifically correlate with difficulty sleeping unless upright.

B. Orthopnea: Difficulty breathing while lying flat (orthopnea) is typically associated with heart failure and would require further investigation to understand its impact on the client's sleep.

C. Edema: While edema can be a sign of cardiovascular problems, it does not directly explain the difficulty in sleeping unless in an upright position.

D. Palpitations: Palpitations might affect sleep but are less directly linked to the need to sleep upright compared to orthopnea.

A. Venous insufficiency ulcers B. Arterial insufficiency ulcers C. Neuropathic ulcers D. Deep vein thrombosis

Correct Answer is B

Explanation

A. Venous insufficiency ulcers: Typically present with dark discoloration and edema, but not specifically with changes in color with elevation and dependency.

B. Arterial insufficiency ulcers: Pale feet when elevated and dark red when dependent are classic signs of arterial insufficiency. These changes in color are due to poor blood flow.

C. Neuropathic ulcers: Usually associated with diabetes and often occur on pressure points, not typically related to color changes with elevation.

D. Deep vein thrombosis: While DVT can cause swelling and pain, it does not usually present with color changes that are dependent on the position of the foot.

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The nurse refers an older adult client for further evaluation after the nurse assesses warm skin and brown pigmentation around the ankles. The nurse suspects which of the following?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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