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. People who abstain from alcohol: Abstaining from alcohol does not necessarily increase the risk of sustaining a traumatic brain injury (TBI). In fact, excessive alcohol consumption can increase the risk of falls and accidents leading to TBIs, but abstaining from alcohol itself is not a risk factor for TBI.

B. People who live in rural areas: Living in rural areas may be associated with certain risk factors for TBIs, such as increased rates of motor vehicle accidents due to factors like higher speed limits and longer distances traveled. However, it is not a direct cause of TBIs.

C. People who play contact sports: Engaging in contact sports, such as football, soccer, or rugby, poses a higher risk of sustaining a traumatic brain injury due to the potential for collisions, falls, and impacts during gameplay.

D. People who are in their 30's: While traumatic brain injuries can occur at any age, individuals who are involved in activities with a higher risk of head injuries, such as contact sports or high-risk occupations, may be more prone to TBIs regardless of their age. Age alone is not a significant risk factor for TBIs.

A. Administer acetaminophen by mouth for pain control B. Perform a thorough health history C. Prepare for a STAT non-contrast CT scan D. Insert an indwelling urinary catheter to monitor urine output

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.

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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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