Nokea
The nurse is assessing the client diagnosed with long-term arterial occlusive disease. Which assessment data support the diagnosis?
- A. Hairless skin on the legs.
- B. Brittle, flaky toenails.
- C. Petechiae on the soles of feet.
- D. Nonpitting ankle edema.
Correct Answer: A
Rationale: Hairless skin (A) indicates chronic ischemia in PAD. Brittle nails (B) are nonspecific, petechiae (C) suggest bleeding, and nonpitting edema (D) is unrelated (pitting edema is venous).
You may also like to solve these questions
Which intervention should the nurse include in the plan of care for a client with an arterial ulcer?
- A. Apply a dry, sterile dressing daily.
- B. Elevate the affected leg above heart level.
- C. Encourage ambulation for 30 minutes daily.
- D. Keep the ulcer moist with a hydrogel dressing.
Correct Answer: D
Rationale: Arterial ulcers require a moist wound environment to promote healing, as dry dressings can adhere to the wound and impair tissue regeneration.
The nurse is teaching the client with peripheral vascular disease. Which interventions should the nurse discuss with the client? Select all that apply.
- A. Wash your feet in antimicrobial soap.
- B. Wear comfortable, well-fitting shoes.
- C. Cut your toenails in an arch.
- D. Keep the area between the toes dry.
- E. Use a heating pad when feet are cold.
Correct Answer: B,D
Rationale: Well-fitting shoes (B) prevent injury, and dry toes (D) prevent infection in PVD. Antimicrobial soap (A) is unnecessary, arched toenails (C) risk ingrown nails, and heating pads (E) risk burns.
The client is one (1) day postoperative abdominal aortic aneurysm repair. Which information from the unlicensed assistive personnel (UAP) would require immediate intervention from the nurse?
- A. The client refuses to turn from the back to the side.
- B. The client’s urinary output is 90 mL in six (6) hours.
- C. The client wants to sit on the side of the bed.
- D. The client’s vital signs are T 98, P 90, R 18, and BP 130/70.
Correct Answer: B
Rationale: Urine output of 90 mL in 6 hours (B) (<30 mL/hr) suggests renal compromise, requiring immediate intervention. Refusing to turn (A), sitting (C), and normal vitals (D) are less urgent.
The nurse is caring for a client diagnosed with deep vein thrombosis. Which information reported to the nurse by the unlicensed assistive personnel (UAP) requires immediate intervention?
- A. The UAP informed the nurse the client is complaining of chest pain.
- B. The UAP notified the nurse the client’s blood pressure is 100/66.
- C. The UAP reported the client is requesting to be able to take a shower.
- D. The UAP tells the nurse the client is asking for medication for a headache.
Correct Answer: A
Rationale: Chest pain in DVT (A) suggests pulmonary embolism, requiring immediate intervention. Hypotension (B), showering (C), and headache (D) are less urgent.
The client is diagnosed with a small abdominal aortic aneurysm. Which interventions should be included in the discharge teaching? Select all that apply.
- A. Tell the client to exercise three (3) times a week for 30 minutes.
- B. Encourage the client to eat a low-fat, low-cholesterol diet.
- C. Instruct the client to decrease tobacco use.
- D. Discuss the importance of losing weight with the client.
- E. Teach the client to wear a truss at all times.
Correct Answer: A,B,C,D
Rationale: Exercise (A), low-fat diet (B), smoking reduction (C), and weight loss (D) reduce AAA progression. Trusses (E) are irrelevant to AAA management.