A nurse is collecting data from a client who has peripheral arterial disease (PAD). Which of the following findings should the nurse expect?
Intermittent claudication
Darkened skin color near extremities
Warm extremities
Edema
The Correct Answer is A
Choice A reason f:Intermittent claudication is a classic symptom of PAD, characterized by muscle pain or cramping in the legs triggered by exercise, such as walking, which typically disappears after a few minutes of rest. This symptom occurs due to inadequate blood flow to the muscles during increased demand.
Choice B reason :Darkened skin color near the extremities, also known as hyperpigmentation, can occur in PAD due to the chronic ischemia and the resultant buildup of waste products in the tissue, which may lead to skin changes.
Choice C reason :Warm extremities are not typically associated with PAD. In fact, patients with PAD may have cooler extremities compared to the rest of the body due to reduced blood flow.
Choice D reason :Edema is not a common finding in PAD. Instead, PAD can lead to decreased skin temperature, loss of hair, shiny skin, and non-healing wounds on the extremities due to poor circulation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason : A low sodium diet is often prescribed for patients with heart conditions to help manage blood pressure and fluid retention. It is not typically something that would need to be questioned in the context of recent pacemaker surgery.
Choice B reason : Checking serum cardiac enzyme levels is a common practice after heart surgery to monitor for any signs of damage to the heart muscle. This would not typically be questioned unless there were specific contraindications for the patient.
Choice C reason : An MRI of the chest should be questioned because MRI machines use strong magnetic fields that can interfere with the functioning of a pacemaker. Unless the pacemaker is specifically labeled as MRI-safe, this type of imaging could be dangerous for the patient.
Choice D reason : Physical therapy is a standard part of recovery after many types of surgery, including pacemaker insertion, to help the patient regain strength and mobility. It would not typically be questioned unless the patient had specific restrictions.
Correct Answer is D
Explanation
Choice A reason : Assisting the client into a standing position is part of the process for checking orthostatic hypotension, but it is not the first action to take. The initial measurement should be taken while the client is supine to establish a baseline blood pressure before any position changes.
Choice B reason : Determining the client's blood pressure 1 minute after each position change is important for diagnosing orthostatic hypotension, but it follows after the initial supine measurement. This step is to observe changes in blood pressure that may indicate orthostatic hypotension.
Choice C reason : Placing the client in a sitting position is another step in the process of checking for orthostatic hypotension. However, it is not the first action. The nurse should first measure the blood pressure in the supine position, then sitting, and finally standing.
Choice D reason : This is the correct first action. Checking the client's blood pressure in a supine position provides a baseline measurement. After this, the nurse can compare the blood pressure readings after the client sits and stands to identify any significant drops that would indicate orthostatic hypotension.
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