A patient at the clinic says, "I always walk after dinner, but lately my leg cramps and hurts after just a few minutes. The pain goes away after I stop walking, though." Which focused assessment would the nurse make?
Assess for unilateral swelling, redness, and tenderness of either leg.
Ask about any skin color changes that occur in response to cold.
Palpate for the presence of dorsalis pedis and posterior tibial pulses.
Look for the presence of tortuous veins bilaterally on the legs.
The Correct Answer is C
Choice A reason: Assessing for unilateral swelling, redness, and tenderness is important when evaluating for conditions such as deep vein thrombosis (DVT). However, this patient's symptoms of leg cramps and pain that subsides with rest are more indicative of peripheral artery disease (PAD) rather than DVT. Therefore, while this assessment is valuable in certain contexts, it is not the most relevant for this patient's symptoms.
Choice B reason: Asking about skin color changes that occur in response to cold can help identify conditions such as Raynaud's phenomenon, which causes extremities to change color in response to cold or stress. However, this patient's symptoms of intermittent leg cramps and pain with walking are more suggestive of PAD, making this question less relevant in this situation.
Choice C reason: Palpating for the presence of dorsalis pedis and posterior tibial pulses is the most appropriate focused assessment. This patient's symptoms of leg cramps and pain that resolve with rest suggest intermittent claudication, which is a hallmark of PAD. By palpating these pulses, the nurse can assess the adequacy of blood flow to the lower extremities, which is crucial in diagnosing PAD.
Choice D reason: Looking for the presence of tortuous veins bilaterally on the legs is important for identifying varicose veins, which are characterized by enlarged, twisted veins. While varicose veins can cause leg discomfort, they are not typically associated with the type of pain that subsides with rest. This patient's symptoms are more indicative of PAD, making this assessment less relevant.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Taking a daily multivitamin with iron is important for overall health, but it is not specifically related to preventing sickle cell crises. While maintaining proper nutrition is essential, it does not directly address the triggers or management of sickle cell crises.
Choice B reason: Restricting fluids to 2 liters per day is not appropriate for patients with sickle cell disease. In fact, maintaining adequate hydration is crucial to prevent sickling of red blood cells and reduce the risk of a sickle cell crisis. Restricting fluids could lead to dehydration, which can exacerbate the condition.
Choice C reason: Limiting exposure to crowds is an important instruction for patients with sickle cell disease. Crowded environments can increase the risk of infections, which can trigger a sickle cell crisis. By avoiding crowded places, patients can reduce their exposure to potential infections and help prevent crises.
Choice D reason: While avoiding caffeinated beverages is generally good advice for overall health, it is not specifically related to preventing sickle cell crises. Caffeine can cause dehydration, but the primary focus for preventing crises is maintaining proper hydration and avoiding infections.
Correct Answer is ["A","B","E","F"]
Explanation
Choice A reason: Monitoring for signs of dehydration is crucial because Mr. Carter's symptoms of nausea and vomiting can lead to fluid loss. Ensuring adequate hydration is essential for maintaining overall health and supporting liver function.
Choice B reason: Providing education about proper hand hygiene is important to prevent the transmission of hepatitis A, especially since Mr. Carter recently traveled to an area where he may have been exposed to the virus. Proper hand hygiene can help reduce the risk of spreading the infection to others.
Choice C reason: Encouraging a high-protein dietary intake is not appropriate in this case. While protein is important for liver repair, Mr. Carter's liver function is compromised, and a high-protein diet may increase the liver's workload. Instead, a balanced diet with adequate calories and nutrients is recommended.
Choice D reason: Administering intravenous antibiotics is not indicated for hepatitis A, as it is a viral infection and not bacterial. Antibiotics would not be effective in treating this condition.
Choice E reason: Advising rest and limiting physical activity is important to support recovery. Mr. Carter's symptoms of fatigue and jaundice indicate that his body needs time to heal. Resting helps conserve energy and allows the liver to recover.
Choice F reason: Educating the patient about the need for lifelong hepatitis A vaccination is crucial. Although hepatitis A does not typically cause chronic infection, vaccination can prevent future infections and protect against the virus.
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