When assessing a client's lower extremities, which finding requires immediate intervention by the nurse?

Multiple varicosities on both thighs.

Lack of hair growth on both lower legs.

Stage 2 pressure injury over the left ankle.

Right calf swelling and tenderness.

Answer and Explanation

The Correct Answer is D

A.   Varicosities, or varicose veins, are dilated veins that appear on the skin and are often associated with venous insufficiency. While they can be symptomatic and require management, they typically do not constitute an immediate medical emergency. Varicosities are generally managed with lifestyle changes, compression therapy, or medical procedures, but they are not usually life-threatening.
B.   Lack of hair growth on the lower legs can indicate poor circulation, commonly seen in conditions like peripheral arterial disease (PAD). While it is a concerning finding and suggests potential arterial insufficiency, it is not usually an immediate emergency.
C.   A Stage 2 pressure injury is characterized by partial-thickness loss of dermis, presenting as a shallow, open ulcer with a pink wound bed. While it requires attention to prevent progression and manage the wound, it is not an immediate emergency compared to other findings that suggest acute complications.

D.   Right calf swelling and tenderness are critical findings that could indicate a deep vein thrombosis (DVT), which is a serious condition where a blood clot forms in a deep vein, usually in the leg. DVT can lead to life-threatening complications such as pulmonary embolism if the clot dislodges and travels to the lungs.

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Correct Answer is B

Explanation

A. Skin turgor assesses skin elasticity and hydration, which is more indicative of general hydration status rather than specific types of insufficiency. While poor skin turgor might be observed in various conditions, it does not specifically differentiate between venous and arterial ulcers.
B. The location and appearance of the ulcer can provide significant clues about its etiology. Venous ulcers often appear on the lower legs, particularly around the medial malleolus (inside of the ankle), and tend to have irregular, shallow, and often wet or weepy edges.
C. Changes in color upon movement can provide insight into the type of insufficiency. For arterial ulcers, the leg may appear pale or blanched when elevated and may develop a reddish or purple color when lowered due to poor blood flow.
D. Measuring joint range of motion assesses flexibility and mobility rather than the type of ulcer. While joint mobility issues can be associated with various conditions, including those affecting the vascular system, it does not directly help in distinguishing between venous and arterial insufficiency ulcers.

A. Loud, at the apex, associated with a palpable thrill. B. Very loud, with no stethoscope, thrill easily palpable, heave visible. C. Soft, barely heard on auscultation in a quiet room. D. Moderately loud, machine-like rumble, not associated with a thrill.

Correct Answer is A

Explanation

A. A grade IV systolic murmur is considered loud and may be associated with a palpable thrill. In mitral valve regurgitation, the murmur is often best heard at the apex of the heart. A thrill, which is a vibration felt on the chest wall, is a sign of a more significant murmur. This description is consistent with a grade IV murmur, which is typically loud and may indeed be associated with a thrill.
B. Very loud, with no stethoscope, thrill easily palpable, heave visible.
B. A grade V systolic murmur is very loud and can be heard with the stethoscope barely touching the chest. It often comes with a palpable thrill and may be accompanied by a visible heave or lift of the

chest wall. This description is consistent with a grade V murmur, not grade IV. Therefore, it’s not the
correct description for a grade IV murmur.
C. A soft murmur, barely audible, describes a grade I or grade II systolic murmur. This does not match the characteristics of a grade IV murmur, which is louder and more easily heard. Therefore, this description does not support a grade IV murmur.
D. A moderately loud murmur, without a thrill, could describe a grade III murmur. Additionally, a "machine-like rumble" is more characteristic of a diastolic murmur, such as those heard in conditions like aortic regurgitation or mitral stenosis, rather than a systolic murmur associated with mitral valve regurgitation.

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When assessing a client's lower extremities, which finding requires immediate intervention by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing an ulcer on a client's lower extremity, which is likely the result of either venous or arterial insufficiency. Which assessment technique should the nurse use to differentiate the pathophysiology causing the ulcer?

Correct Answer is B

Explanation

The nurse auscultates the precordium of a client who is diagnosed with mitral valve regurgitation and hears a grade IV systolic murmur. When documenting the comparison of systolic murmurs, which characteristics should the nurse use to support this systolic finding?

Correct Answer is A

Explanation

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To confirm the presence of steatorrhea, which action should the nurse take?

Patient Data Exhibits