Nokea
The nurse is performing a physical assessment of a client. Which finding should the nurse recognize is a result of a compromised peripheral arterial circulation of the lower extremity?
- A. Bronze pigmentation.
- B. Lower leg edema.
- C. Uneven hair distribution.
- D. Bounding peripheral pulse.
Correct Answer: C
Rationale: Uneven hair distribution, such as decreased hair growth, is indicative of compromised peripheral arterial circulation due to reduced blood flow to the area.
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A client with psoriasis returns to the clinic reporting the persistence of several silvery, scaly areas on the elbows and palms that frequently burn and sometimes bleed. Which prescription should the nurse teach the client to use for the skin condition?
- A. Topical antifungal.
- B. Topical corticosteroids.
- C. Topical analgesics.
- D. Colloidal oatmeal based lotion.
Correct Answer: B
Rationale: Topical corticosteroids are commonly used to reduce inflammation and itching associated with psoriasis, controlling symptoms and promoting healing.
The nurse is assessing a client who has herpes zoster. Which question will allow the nurse to gather further information about this condition?
- A. Have the antifungal creams been effective?
- B. Do your family members share combs and brushes?
- C. Do you have any dry patches on your feet and hands?
- D. Has everyone at home already had varicella?
Correct Answer: D
Rationale: Asking whether everyone at home has had varicella is important, as herpes zoster can transmit the varicella-zoster virus to non-immune individuals, causing chickenpox.
After falling down the basement steps, a client is brought to the emergency department. X-ray results confirm that the client's right leg is fractured. Following application of a leg cast, which assessment finding warrants immediate intervention by the nurse?
- A. Right foot pale with sluggish capillary refill.
- B. Circumferential edema of right foot.
- C. Reports throbbing right leg pain.
- D. Increased temperature to lower extremity.
Correct Answer: A
Rationale: A pale right foot with sluggish capillary refill suggests compromised circulation, possibly due to compartment syndrome, requiring immediate intervention to prevent tissue damage.
The nurse is caring for a client after a coronary artery bypass graft surgery. The client is exhibiting pitting edema of the lower extremities and jugular venous distention with increased central venous pressure. Which condition should the nurse suspect the client is experiencing based on these findings?
- A. Internal bleeding.
- B. Right-sided heart failure.
- C. Cardiac tamponade.
- D. Left ventricular dysfunction.
Correct Answer: B
Rationale: Right-sided heart failure can cause systemic venous congestion, leading to pitting edema and jugular venous distention due to increased central venous pressure.
A client is admitted to the hospital for treatment of a simple goiter, and levothyroxine sodium is prescribed. Which symptoms indicate to the nurse that the prescribed dosage is too high for this client?
- A. Palpitations and shortness of breath.
- B. Bradycardia and constipation.
- C. Muscle cramping and dry, flushed skin.
- D. Lethargy and lack of appetite.
Correct Answer: A
Rationale: Palpitations and shortness of breath are symptoms of thyrotoxicosis, indicating excessive thyroid hormone levels, which could result from an overdose of levothyroxine.