A home health nurse is seeing an elderly male client for the first time. During the physical assessment of the skin on the lower legs the skin is pale and cool to touch. The nurse notes small circular ulcers on the soles of his feet. From these findings, the nurse knows that the client has a problem with circulation. Which of the circulation condition does the nurse suspect?
Necrotic wound
Trauma
Venous insufficiency
Arterial insufficiency
The Correct Answer is D
The findings of pale and cool skin on the lower legs, along with small circular ulcers on the soles of the feet, are indicative of arterial insufficiency. Arterial insufficiency occurs when there is a decreased blood flow to the extremities, often due to conditions such as atherosclerosis or peripheral arterial disease. This reduced blood flow can result in pale and cool skin, as well as the development of ulcers, which are typically round and have well-defined borders. It is essential to assess and manage arterial insufficiency promptly to prevent complications like tissue necrosis and gangrene.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "I will reduce my intake of sodium." - This statement is correct. High sodium intake can lead to increased calcium excretion through the urine, which can weaken bones. Reducing sodium intake can help prevent osteoporosis.
B. "I will limit my intake of soft drinks." - This statement is correct. Soft drinks, especially cola beverages, contain phosphoric acid, which can leach calcium from bones, leading to decreased bone density. Limiting soft drink consumption is advisable for bone health.
C. "I will decrease my intake of caffeine." - This statement is correct. Excessive caffeine consumption can interfere with calcium absorption and increase calcium excretion. It is advisable to limit caffeine intake to prevent osteoporosis.
D. "I will reduce my intake of vitamin K-rich foods." - This statement is incorrect. Vitamin K is essential for bone health as it helps in bone mineralization and reduces the risk of fractures. Foods rich in vitamin K, such as leafy green vegetables, are beneficial for bone health and should not be reduced unless there are specific medical reasons to do so.
Correct Answer is D
Explanation
A. Void every 6 to 8 hours:This interval may not be frequent enough. It is generally recommended to void every 2 to 3 hours to help flush out bacteria and reduce the risk of infection.
B. Avoid voiding immediately after sexual intercourse.This is not recommended. It is actually advised to void immediately after sexual intercourse to help flush out any bacteria that may have entered the urethra.
C. Take a bubble bath daily and keep the perineal region clean:
While keeping the perineal region clean is important for general hygiene, taking bubble baths and using heavily scented products can irritate the urethra and potentially increase the risk of UTIs. The nurse should advise against frequent bubble baths and suggest using mild, unscented soaps for the perineal area.
D. Increase the daily amount of water consumed:
Drinking more water helps increase urine output, which helps flush out bacteria from the urinary tract and can reduce the risk of recurrent UTIs.
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