An obese post-surgical patient reports sudden discomfort in her leg.
Upon assessment, the nurse finds the leg to be cold and pale, with no pedal or popliteal pulse. What should the nurse suspect?
Venous thrombosis.
Paresthesia.
Vascular spasm.
Arterial occlusion.
The Correct Answer is D
Choice A rationale
Venous thrombosis is a condition in which a blood clot forms in a vein, typically in the leg. While this condition can cause discomfort and changes in the appearance of the leg, it would not typically cause the leg to become cold and pale or result in the loss of a pulse.
Choice B rationale
Paresthesia refers to abnormal sensations in the body, such as tingling, numbness, or burning. While this condition could potentially cause discomfort, it would not typically cause the leg to become cold and pale or result in the loss of a pulse.
Choice C rationale
Vascular spasm is a sudden, brief tightening of the muscles inside the walls of a blood vessel. While this could potentially cause discomfort and changes in the appearance of the leg, it would not typically cause the leg to become cold and pale or result in the loss of a pulse.
Choice D rationale
Arterial occlusion is the correct answer. This condition involves a blockage in an artery, which can significantly reduce blood flow to the affected area. This could cause the leg to become cold and pale and result in the loss of a pulse.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Standing frequently can help promote blood flow in the legs, which can be beneficial for a patient with arterial insufficiency. This is because standing engages the muscles in the legs, which helps push blood back up towards the heart.
Choice B rationale
Walking without shoes is not typically recommended for patients with arterial insufficiency. This is because these patients often have reduced sensation in their feet and may not notice if they step on something sharp or if a wound develops.
Choice C rationale
Vigorous massage of the legs is not usually recommended for patients with arterial insufficiency. While gentle massage can help promote blood flow, vigorous massage could potentially damage the arteries further.
Choice D rationale
Allowing the legs to dangle dependently often is not typically recommended for patients with arterial insufficiency. This position can actually increase swelling and discomfort in the legs.
Correct Answer is B
Explanation
Choice A rationale
Sinus tachycardia is a regular, rapid heart rate caused by rapid firing of the sinoatrial node. It is characterized by a heart rate of greater than 100 beats per minute, and P waves are present before each QRS complex. This does not match the description given.
Choice B rationale
Ventricular tachycardia is a fast, regular beating of the ventricles that may last for only a few seconds or for much longer. In this condition, the ventricular rate is often between 120 and 200 beats per minute, and P waves are not associated with the QRS complexes. This matches the description given.
Choice C rationale
Ventricular fibrillation is a severe condition in which the heart beats with rapid, erratic electrical impulses. This causes the ventricles to quiver uselessly instead of pumping blood. The description does not match this condition.
Choice D rationale
Atrial flutter is a condition that shares similarities with atrial fibrillation, both involve an irregular heartbeat. However, atrial flutter is more organized and less chaotic than atrial fibrillation, which can make it more manageable. The description does not match this condition.
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