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 C

Explanation

A. Administer acetaminophen by mouth for pain control: While pain management is important, it is not the priority intervention in this situation. Administering acetaminophen for pain control can be done after the client's condition has been assessed and any potential serious injuries, such as head trauma, have been addressed.

B. Perform a thorough health history: Obtaining a health history is essential for understanding the client's baseline health status and any pre-existing conditions that may affect their current condition. However, in the acute phase following a traumatic fall, the priority is to assess and manage any potential life-threatening injuries.

C. Prepare for a STAT non-contrast CT scan: This is the correct answer. In cases of traumatic falls, particularly when there is concern for head injury or intracranial bleeding, obtaining a non-contrast CT scan of the head is a priority. This imaging study helps identify any intracranial injuries such as hemorrhage or skull fractures, allowing for prompt intervention if necessary.

D. Insert an indwelling urinary catheter to monitor urine output: Monitoring urine output is important for assessing renal function, but it is not the priority intervention in the immediate aftermath of a traumatic fall. The focus initially should be on assessing and managing potential life-threatening injuries, particularly those related to head trauma.

A. "Blood flow is altered and causes blood to pool in the legs." B. "Blood flow is altered due to atherosclerosis affecting the tissues' ability to receive oxygen-rich blood." C. "Blood flow is altered due to incompetent valves causing increased venous pressure." D. "Blood flow is altered due to excessive stretching of the ventricles impairing the heart to contract."

Correct Answer is B

Explanation

A. "Blood flow is altered and causes blood to pool in the legs." This statement inaccurately describes venous insufficiency rather than peripheral arterial disease (PAD). In PAD, blood flow is reduced or obstructed due to atherosclerosis, leading to inadequate oxygen supply to tissues rather than pooling of blood in the legs.

B. "Blood flow is altered due to atherosclerosis affecting the tissues' ability to receive oxygen-rich blood." This statement correctly explains the underlying pathology of peripheral arterial disease (PAD). Atherosclerosis, characterized by the buildup of plaque in the arteries, narrows or blocks blood flow, impairing the delivery of oxygen-rich blood to the tissues. This can result in symptoms such as pain, cramping, and tissue damage, especially during activity when oxygen demand increases.

C. "Blood flow is altered due to incompetent valves causing increased venous pressure." This statement describes venous insufficiency rather than PAD. In venous insufficiency, faulty valves in the veins result in increased venous pressure, leading to symptoms such as swelling, heaviness, and varicose veins, but it does not involve arterial obstruction as seen in PAD.

D. "Blood flow is altered due to excessive stretching of the ventricles impairing the heart to contract." This statement describes a condition related to the heart's function rather than peripheral arterial disease. Excessive stretching of the ventricles may occur in conditions such as heart failure, but it does not directly affect blood flow in the peripheral arteries as seen in PAD.

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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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