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 B
Explanation
A. Morse Scale:
The Morse Scale, also known as the Morse Fall Scale, is used to assess a patient's risk of falling. It evaluates various factors such as history of falling, secondary diagnosis, ambulatory aids, IV therapy, gait, and mental status. It is primarily focused on assessing the risk of falls, not pressure ulcers.
B. Braden Scale:
As previously mentioned, the Braden Scale assesses a patient's risk for developing pressure ulcers. It takes into account sensory perception, moisture, activity, mobility, nutrition, and friction/shear. The scale helps healthcare providers determine the level of risk a patient has for developing pressure sores and guides interventions to prevent them.
C. Bristol Scale:
The Bristol Stool Scale is used to classify the form of human feces into seven categories. It is a medical aid designed to classify the form of human feces into seven categories. This scale is primarily used to assess bowel movements and is unrelated to pressure ulcers.
D. Hendrich II Scale:
The Hendrich II Fall Risk Model is a tool designed to identify patients at risk for falls. It includes factors such as confusion, symptomatic depression, altered elimination, dizziness, male gender, and the use of antiepileptics, benzodiazepines, or non-opioid analgesics. Similar to the Morse Scale, it focuses on assessing the risk of falls, not pressure ulcers.
Correct Answer is B
Explanation
A. There is no need for the client to lie flat for an extended period after a DEXA scan. The procedure is non-invasive and does not require immobilization.
B. Emptying the bladder before the test is essential to ensure a clear and accurate scan of the pelvis and lower spine. A full bladder might obstruct the view and affect the accuracy of the results.
C. DEXA scans do not typically require the use of IV dye. It is a simple X-ray procedure that measures bone density, and no contrast material is usually needed.
D. Fasting is not necessary for a DEXA scan. The procedure does not involve ingesting or injecting any substances that require fasting.
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