A nurse is caring for a client who has diabetic ketoacidosis (DK

Choice A reason: Lower Extremities Edematous with Decreased Pulses and Cool to the Touch

Lower extremities that are edematous with decreased pulses and cool to the touch can indicate severe peripheral artery disease (PAD) and poor blood circulation1. While this is a serious condition that requires medical attention, it is not necessarily an immediate emergency unless there are signs of acute limb ischemia, such as sudden pain or loss of function. Chronic symptoms like these often require ongoing management and monitoring rather than immediate intervention.

Choice B reason: Pain, Pallor, and Paresthesia in the Foot

Pain, pallor, and paresthesia (the three Ps) in the foot are classic signs of acute limb ischemia, a medical emergency that requires immediate intervention. Acute limb ischemia occurs when there is a sudden decrease in blood flow to a limb, leading to tissue damage and potential loss of the limb if not treated promptly4. The presence of these symptoms indicates that the limb is not receiving adequate blood supply, necessitating urgent medical attention to restore circulation and prevent permanent damage.

Choice C reason: Presence of an Open Wound Near the Ankle with Serous Drainage and Pruritus

An open wound near the ankle with serous drainage and pruritus (itching) suggests a chronic wound or ulcer, which is common in patients with PAD5. While this condition requires medical treatment to prevent infection and promote healing, it does not typically constitute an immediate emergency unless there are signs of severe infection, such as increased redness, warmth, or purulent drainage. Chronic wounds need regular care and monitoring but are not usually life-threatening.

Choice D reason: Murmur Auscultated at the Left Sternal Border, Slight Dyspnea, and Lower Extremity Edema

A murmur auscultated at the left sternal border, slight dyspnea (shortness of breath), and lower extremity edema can indicate heart valve disease or heart failure. These symptoms are concerning and require medical evaluation, but they do not typically represent an immediate emergency unless the patient is experiencing severe symptoms such as acute heart failure or cardiogenic shock. These conditions require prompt but not necessarily emergent intervention.

Choice A reason:

“I need to walk slowly as I lose my balance often” is a significant safety concern for a client with peripheral artery disease (PAD). Balance issues can increase the risk of falls, which can lead to serious injuries, especially in clients with compromised circulation. PAD can cause muscle weakness and pain, which may contribute to balance problems. Reporting this symptom to the provider is crucial for further evaluation and intervention to prevent falls and improve the client’s mobility and safety.

Choice B reason:

“I have a small-healed area on my spine that is painful” is not directly related to peripheral artery disease. While pain in different parts of the body can be concerning, this statement does not indicate an immediate safety risk associated with PAD. However, it is still important for the nurse to document and monitor this symptom, as it could be related to other underlying conditions.

Choice C reason:

“I don’t go out much because of the pain in my legs” is a common symptom of PAD known as claudication, which is pain caused by too little blood flow during exercise. While this statement indicates a significant impact on the client’s quality of life, it does not pose an immediate safety risk that requires urgent reporting. The nurse should provide education on managing claudication and encourage the client to engage in supervised exercise programs to improve circulation.

Choice D reason:

“It makes me sad that I can’t keep up with my grandchildren” reflects the emotional and psychological impact of PAD on the client’s life. While this is an important aspect of the client’s overall well-being, it does not represent an immediate safety concern. The nurse should address the client’s emotional health and consider referring them to a mental health professional for support.