A nurse is assessing a client who has peripheral artery disease. Which of the following findings should the nurse recognize as requiring immediate intervention?

Lower extremities edematous with decreased pulses and cool to the touch

Pain, pallor, and paresthesia in the foot

Murmur auscultated at the left 5th midclavicular line, slight dyspnea, and lower extremity edema

Presence of an open wound near the ankle with serous drainage and pruritus

Answer and Explanation

The Correct Answer is B

A. Lower extremities edematous with decreased pulses and cool to the touch While this finding suggests impaired circulation associated with peripheral artery disease, it does not indicate an immediate need for intervention. However, it requires timely assessment and intervention to prevent further complications.

B. Pain, pallor, and paresthesia in the foot This finding indicates critical limb ischemia, which is a severe complication of peripheral artery disease requiring immediate intervention. Pain, pallor (pale color), and paresthesia (abnormal sensations like tingling or numbness) suggest inadequate blood flow to the affected limb, putting the client at risk for tissue damage and limb loss if not promptly addressed.

C. Murmur auscultated at the left 5th midclavicular line, slight dyspnea, and lower extremity edema These findings are suggestive of cardiac issues such as heart failure rather than immediate complications of peripheral artery disease. While they require attention, they do not signify an urgent need for intervention specific to peripheral artery disease.

D. Presence of an open wound near the ankle with serous drainage and pruritus While an open wound warrants assessment and appropriate wound care, it does not indicate an immediate need for intervention unless there are signs of infection or severe tissue damage. In this scenario, the presentation of pain, pallor, and paresthesia indicates a more urgent need for intervention to prevent tissue necrosis and limb loss.

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Correct Answer is D

Explanation

Cushing's Triad is a set of three classic signs associated with increased intracranial pressure (ICP). These signs include hypertension, bradycardia, and irregular respirations. The presence of Cushing's Triad indicates severe brain injury or increased ICP, often leading to brainstem compression.

A. Tachycardia (Option A): Increased intracranial pressure can initially lead to tachycardia as the body attempts to compensate for the changes. However, as ICP continues to rise and brainstem compression occurs, the sympathetic response diminishes, resulting in bradycardia rather than tachycardia. Therefore, Cushing's Triad is not associated with preventing tachycardia.

B. Agonal breathing (Option B): Agonal breathing, characterized by gasping, labored breathing, or irregular breathing patterns, may occur as a result of brainstem dysfunction or damage. Cushing's Triad, indicative of increased ICP and impending brainstem herniation, does not prevent agonal breathing. In fact, irregular respirations are part of Cushing's Triad.

C. Chest pain (Option C): Chest pain may occur due to various cardiac or respiratory conditions and is not directly related to Cushing's Triad or increased intracranial pressure. Therefore, Cushing's Triad does not prevent chest pain.

D. Brainstem ischemia (Option D): Increased intracranial pressure can lead to brainstem compression, compromising blood flow to the brainstem and resulting in brainstem ischemia. Cushing's Triad, characterized by hypertension, bradycardia, and irregular respirations, is a nervous system response indicative of severe brain injury or increased ICP, which can lead to brainstem ischemia if left untreated. Therefore, Cushing's Triad is associated with brainstem ischemia rather than preventing it.

A. Pantoprazole B. Warfarin C. Furosemide D. Oxybutynin

Correct Answer is C

Explanation

Pantoprazole: Pantoprazole is a proton pump inhibitor commonly used to reduce stomach acid production. It is primarily indicated for the treatment of gastroesophageal reflux disease (GERD), peptic ulcers, and other conditions related to excessive stomach acid production. It does not play a role in managing Meniere's disease, which is a disorder of the inner ear characterized by episodes of vertigo, tinnitus, and hearing loss.

B) Warfarin: Warfarin is an anticoagulant medication used to prevent blood clot formation. It is commonly prescribed for conditions such as atrial fibrillation, deep vein thrombosis, and pulmonary embolism. Meniere's disease does not typically require anticoagulant therapy, so warfarin would not be indicated for its treatment.

C) Furosemide: Furosemide is a loop diuretic that helps reduce fluid retention by increasing urine output. In some cases of Meniere's disease, especially those associated with excessive endolymphatic fluid buildup in the inner ear, furosemide may be prescribed to help reduce fluid volume and alleviate symptoms such as vertigo and pressure sensation in the ear.

D) Oxybutynin: Oxybutynin is an anticholinergic medication primarily used to treat overactive bladder and urinary incontinence. It works by relaxing smooth muscle in the bladder, reducing bladder spasms and urinary urgency. While some individuals with Meniere's disease may experience associated symptoms such as frequent urination or urinary urgency, oxybutynin is not a standard treatment for Meniere's disease itself.

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A nurse is assessing a client who has peripheral artery disease. Which of the following findings should the nurse recognize as requiring immediate intervention?

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Correct Answer is D

Explanation

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Correct Answer is C

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