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 C
Explanation
A. Increased thickness of the subcutaneous skin layer - Aging typically results in thinning of the skin and subcutaneous tissue, making older adults more vulnerable to pressure ulcers rather than having increased thickness.
B. Changes in the character and quantity of bacterial skin flora - This is a common age-related change; however, it is not directly related to the course of treatment for a sacral pressure ulcer. Proper wound care can mitigate the impact of changes in skin flora.
C. Increased time required for wound healing - Aging often leads to a decline in the body's ability to repair and regenerate tissues, which can prolong the healing process of wounds, including pressure ulcers. Older adults may experience delayed wound healing compared to younger individuals.
D. Increased elasticity of the skin - Skin elasticity decreases with age, making older adults more susceptible to skin breakdown and pressure ulcers due to reduced skin resilience and ability to redistribute pressure. Increased elasticity would not affect the course of treatment positively but rather negatively in this context.
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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