An older patient with chronic atrial fibrillation develops sudden severe pain, pulselessness, pallor, and coolness in the right leg, consistent with acute arterial occlusion.
After the nurse notifies the healthcare provider, what should the nurse do next?
Elevate the leg above the level of the heart.
Assist the patient in gently exercising the leg.
Apply a compression stocking to the leg.
Keep the patient in bed in the supine position.
The Correct Answer is D
Choice A rationale
Elevating the leg above the level of the heart would not be beneficial in this case. This action would actually reduce blood flow to the leg, which is already compromised due to the arterial occlusion.
Choice B rationale
Exercising the leg would increase the oxygen demand of the tissues in the leg, which could exacerbate the problem. The tissues in the leg are already deprived of oxygen due to the arterial occlusion.
Choice C rationale
Applying a compression stocking to the leg would not be beneficial in this case. This action would further compromise blood flow to the leg, which is already reduced due to the arterial occlusion.
Choice D rationale
Keeping the patient in bed in the supine position is the correct action. This position will decrease the oxygen demand of the tissues in the leg and minimize ischemic damage until circulation can be restored.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
Choice A rationale
Rheumatoid arthritis is an autoimmune disease that primarily affects the joints. While it can increase the risk of cardiovascular disease due to systemic inflammation, it is not typically considered a direct cause of secondary hypertension.
Choice B rationale
Coarctation of the aorta, a congenital condition characterized by a narrowing of the aorta, can cause secondary hypertension. This is because the narrowing can increase resistance to blood flow, leading to increased pressure.
Choice C rationale
Increased intracranial pressure (ICP) can cause secondary hypertension as part of Cushing’s reflex, a physiological response to protect the brain from damage. This reflex can lead to an increase in systemic blood pressure in an attempt to maintain cerebral perfusion.
Choice D rationale
Renal disease is a common cause of secondary hypertension. The kidneys play a crucial role in regulating blood pressure, and damage to the kidneys can lead to hypertension.
Choice E rationale
Colon cancer is not typically associated with secondary hypertension. While some cancers can produce substances that increase blood pressure, colon cancer is not commonly associated with this phenomenon.
Correct Answer is B
Explanation
Choice A rationale
Ulceration on the medial surface of the lower legs is not the best description of stasis dermatitis in a patient with peripheral vascular disease (PVD). While ulcers can occur in severe cases, they are not the primary characteristic of stasis dermatitis.
Choice B rationale
Stasis dermatitis, also known as venous stasis dermatitis, is a skin inflammation that occurs in people with poor circulation. It most often happens in the lower legs because that’s where blood typically collects. When blood pools in the veins of the lower leg, it can cause a variety of symptoms, including a brownish skin discoloration on the lower legs. This discoloration is caused by the leakage of red blood cells into the skin due to increased pressure in the veins.
Choice C rationale
While edema in the lower legs can be a symptom of PVD and may accompany stasis dermatitis, it is not the best description of the condition. Edema is a general symptom that can occur in many conditions and is not specific to stasis dermatitis.
Choice D rationale
A purple rash on the medial surface of the lower legs is not a typical symptom of stasis dermatitis. While the skin may become discolored, it is usually a brownish color rather than purple.
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