A nurse is teaching a client with chronic peripheral artery disease. What client statement indicates the need for further teaching?
"I will avoid long periods of sitting down with my legs crossed over."
"I will walk to the point of pain, rest, and walk again for at least 30 minutes."
"I will use a heating pad on my feet at night to increase the circulation."
"I will buy some loose clothes that do not bind across my legs or waist."
The Correct Answer is C
"I will use a heating pad on my feet at night to increase the circulation.": Using a heating pad on the feet at night is not recommended for clients with peripheral artery disease. The application of heat, such as from a heating pad, can dilate blood vessels and potentially worsen the symptoms of peripheral artery disease. This can lead to reduced blood flow to the affected limbs and increase the risk of complications.
The other client statements demonstrate an understanding of peripheral artery disease management:
"I will avoid long periods of sitting down with my legs crossed over." This statement shows awareness of the importance of maintaining good blood flow and avoiding positions that can restrict circulation.
"I will walk to the point of pain, rest, and walk again for at least 30 minutes." This statement indicates an understanding of the concept of intermittent claudication, a common symptom of peripheral artery disease. Walking until pain occurs, resting, and then resuming walking helps improve circulation and increases walking distance over time.
"I will buy some loose clothes that do not bind across my legs or waist." This statement reflects an awareness of the need to wear loose-fitting clothes that do not constrict blood flow to the legs or waist area.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The most important finding to report to the health care provider would be the serum potassium level of 3.0 mEq. This is an extremely low potassium level (normal range is typically 3.5-5.0 mEq/L), which can indicate a potentially life-threatening condition called hypokalemia. Furosemide (Lasix) is a diuretic medication that can cause potassium loss in the urine, and a low potassium level can lead to serious cardiac and muscle abnormalities. It is crucial to report this finding promptly to the health care provider for appropriate intervention and monitoring.
Blood glucose level of 175 mg/dL: While an elevated blood glucose level can be a concern, especially for individuals with diabetes, it is not the most critical finding in this situation. The client's primary concern is hypertension, and the administration of IV furosemide is aimed at managing blood pressure. The elevated blood glucose level should still be addressed and monitored, but it is not as urgent as the low potassium level.
Orthostatic systolic BP decrease of 12 mm Hg: Orthostatic hypotension refers to a significant decrease in blood pressure upon standing up. While it is important to assess and manage orthostatic changes, a decrease of 12 mm Hg in systolic blood pressure alone may not be considered clinically significant. It could be a normal response for some individuals. However, if the client experiences symptoms such as dizziness or lightheadedness upon standing, further evaluation may be necessary. Nonetheless, it is not as urgent as the low potassium level.
Current blood pressure reading of 166/94 mm Hg: While this blood pressure reading indicates hypertension, it is not the most critical finding to report in this situation. The nurse is preparing to administer furosemide (Lasix), which is a medication commonly used to treat hypertension. It is expected that the blood pressure will be high before administering the medication. The goal is to monitor the blood pressure after the administration to assess the effectiveness of the medication.
Correct Answer is B
Explanation
Abdominal aortic aneurysms (AAA) often do not present with specific symptoms in the early stages. It is not uncommon for individuals with AAA to be asymptomatic or have vague symptoms. Therefore, the absence of abdominal pain or any problems related to the abdomen is a common finding during the assessment of a client with an abdominal aortic aneurysm.
Let's briefly review the other statements:
"I have stomach pain every time I eat a big, heavy meal": This statement is more suggestive of gastrointestinal issues such as indigestion or acid reflux rather than specifically related to an abdominal aortic aneurysm.
"I have periodic episodes of constipation and then diarrhea": This statement may indicate gastrointestinal issues, but it is not a typical symptom associated with an abdominal aortic aneurysm. AAA is primarily related to the aorta, the main blood vessel in the abdomen, and its symptoms are not directly linked to bowel function.
"I belch a lot, especially when I lay down after eating": This statement suggests gastrointestinal symptoms such as acid reflux or gastroesophageal reflux disease (GERD). While these symptoms may be unrelated to the abdominal aortic aneurysm itself, they can coexist with other conditions.
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