A nurse is caring for a client who has peripheral arterial disease (PAD). Which of the following symptoms should the nurse expect to find in the early stage of the disease?
Dependent rubor
Intermitent claudication
Foot ulcers
Rest pain
The Correct Answer is B
The correct answer is B
Choice B reason: Intermittent claudication
Intermittent claudication is a characteristic symptom of PAD in the early stage, due to the reduced blood flow to the muscles during exercise. It is a cramping pain in the legs that occurs with walking and is relieved by rest.
Choice A reason: Dependent rubor is a sign of PAD in the advanced stage, due to the impaired vasodilation and reactive hyperemia. It is a reddish color of the lower extremities that occurs when they are lowered and disappears when they are elevated.
Choice C reason: Foot ulcers are a complication of PAD in the late stage, due to the poor wound healing and tissue necrosis. They are usually located on the toes, heels, or pressure points.
Choice D reason: Rest pain is another sign of PAD in the late stage, due to the severe ischemia and nerve damage. It is a persistent pain in the feet or toes that occurs at night and is not relieved by rest.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Frothy sputum is a sign of left-sided heart failure, due to the pulmonary congestion and impaired gas exchange. The sputum may be pink-tinged or blood-streaked, indicating pulmonary edema.
a. Dependent edema is more likely to be seen in clients who have right-sided heart failure, due to the increased venous pressure and fluid retention. The edema is usually symmetrical and affects the lower extremities, abdomen, and sometimes the face.
c. Nocturnal polyuria is not a specific finding of left-sided heart failure, but it may occur in clients who have renal impairment, diabetes mellitus, or diuretic therapy.
d. Jugular distention is another sign of right-sided heart failure, due to the increased central venous pressure and backward flow of blood into the superior vena cava. It is visible as a bulging of the neck veins, especially when the client is in a semi-Fowler's position.
Correct Answer is D
Explanation
A headache is a common and expected adverse effect of nitroglycerin, due to its vasodilating action. The client can take an over-the-counter analgesic to relieve the headache, unless contraindicated.
"A headache is an indication of an allergy to the medication." is not correct, as a headache is not a sign of an allergic reaction to nitroglycerin. An allergic reaction would manifest as rash, itching, swelling, or difficulty breathing.
"A headache indicates tolerance to the medication." is not accurate, as a headache does not indicate tolerance to nitroglycerin. Tolerance would manifest as reduced or absent relief from anginal pain.
"A headache is likely due to the anxiety about the chest pain." is not plausible, as a headache is not likely due to the anxiety about the chest pain. Anxiety would manifest as nervousness, restlessness, palpitations, or sweating.
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