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 ["250"]
Explanation
To calculate the infusion rate, you first need to determine the total volume to be infused and the total time over which the infusion will occur.
Three 1L bags need to be infused over 12 hours.
Total volume = 3 bags * 1000 mL/bag = 3000 mL
Total time = 12 hours
Now, to find the rate in milliliters per hour (mL/h), divide the total volume by the total time:
Infusion rate = Total volume / Total time
Infusion rate = 3000 mL / 12 hours = 250 mL/h
Correct Answer is A
Explanation
A. "I will reduce my intake of vitamin K-rich foods."
Vitamin K is essential for bone health as it helps in the regulation of calcium within bones and blood vessels. Therefore, reducing the intake of vitamin K-rich foods would not be beneficial for preventing osteoporosis. In fact, adequate intake of vitamin K is important for bone health.
B. "I will limit my intake of soft drinks." - Soft drinks, especially cola beverages, contain phosphoric acid, which can leach calcium from bones, making them weaker and more susceptible to fractures.
C. "I will reduce my intake of sodium." - High sodium intake can lead to increased calcium excretion in the urine, potentially weakening bones over time. Reducing sodium intake can help in preventing bone loss.
D. "I will decrease my intake of caffeine." - Excessive caffeine consumption can interfere with calcium absorption, contributing to bone loss. Decreasing caffeine intake is advisable for maintaining bone health.
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