For a client diagnosed with peripheral arterial disease who has been taking aspirin 81 mg daily prophylactically for several months, which assessment finding is of most concern?

Hemoglobin is 7.1 g/dL on today's laboratory report.

There are small areas of ecchymosis on the client's upper extremities.

Platelet count is 148,000/uL on today's laboratory report.

The client complains of gastrointestinal discomfort after taking the medication.

Answer and Explanation

The Correct Answer is A

Choice A Reason
A hemoglobin level of 7.1 g/dL is significantly lower than the normal range, which is typically around 13.8 to 17.2 g/dL for men and 12.1 to 15.1 g/dL for women. This finding is concerning as it indicates severe anemia, which can be a life-threatening condition requiring immediate intervention. Anemia can lead to tissue hypoxia as the blood's capacity to carry oxygen is diminished. In the context of peripheral arterial disease, where blood flow is already compromised, anemia can exacerbate symptoms and increase the risk of ischemic events.

Choice B Reason
Ecchymosis, or bruising, on the client's upper extremities could be a result of the antiplatelet effects of aspirin, which inhibits platelet aggregation and prolongs bleeding time. While this is a concern and warrants monitoring, it is not as immediately life-threatening as severe anemia. However, it does indicate a risk of bleeding complications, which should be addressed by the healthcare provider.

Choice C Reason
A platelet count of 148,000/uL is at the lower end of the normal range, which is approximately 150,000 to 450,000 platelets per microliter of blood. This finding should be monitored, especially in the context of aspirin therapy, which can affect platelet function. However, it is not as critical as the low hemoglobin level.

Choice D Reason
Gastrointestinal discomfort is a common side effect of aspirin due to its irritation of the stomach lining. While this symptom can be uncomfortable and may lead to more serious gastrointestinal issues such as ulcers or bleeding, it is typically not as urgent as severe anemia. The client should be evaluated for potential gastrointestinal complications of aspirin therapy.

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Correct Answer is ["B","D","E"]

Explanation

Choice A Reason:
A glucose level of at least 600 mg/dL is more indicative of hyperglycemic hyperosmolar state (HHS) rather than diabetic ketoacidosis (DKA). While both conditions involve high blood sugar levels, DKA is typically characterized by blood glucose levels that are high but not as extreme as those seen in HHS1.

Choice B Reason:
A fruity, acetone smell to the breath is a classic sign of DKA. This odor is due to the presence of ketones, particularly acetone, which is exhaled. It’s one of the key clinical manifestations that can help in the diagnosis of DKA.

Choice C Reason:
The absence of ketones in the urine would not be consistent with a diagnosis of DKA. One of the hallmarks of DKA is the presence of ketones in the urine, resulting from the breakdown of fats due to a lack of insulin.

Choice D Reason:
Polyuria (excessive urination) and polydipsia (excessive thirst) are symptoms of DKA. They occur as the body tries to eliminate excess glucose through the urine, which can lead to dehydration and the need to drink more fluids.

Choice E Reason:
Rapid, deep breathing, also known as Kussmaul respiration, is a compensatory mechanism for the acidosis seen in DKA. The body attempts to correct the acidic pH by exhaling more carbon dioxide.

A. Avoiding frustrating the client by performing ADLs for the client. B. Telling jokes or riddles and discussing new items. C. Bringing new topics and options to the client's attention. D. Assisting the client to perform simple tasks by giving step-by-step directions.

Correct Answer is D

Explanation

Choice A Reason:
Avoiding frustration by performing activities of daily living (ADLs) for the client may seem helpful, but it can actually lead to increased dependency and a faster decline in the ability to perform these tasks. It is important to encourage independence as much as possible.

Choice B Reason:
Telling jokes or riddles and discussing new items might provide temporary entertainment but does not necessarily help a client with dementia function better in their environment. It could also potentially cause confusion or frustration if the client does not understand or remember the context.

Choice C Reason:
Bringing new topics and options to the client's attention can be overwhelming and may contribute to confusion. Clients with dementia benefit from consistency and routine, which helps them feel more secure and oriented.

Choice D Reason:
Assisting the client to perform simple tasks by giving step-by-step directions is a beneficial intervention. It supports the client's ability to maintain independence and function within their environment for as long as possible. This approach aligns with the goal of maximizing the client's abilities and fostering a sense of accomplishment.

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For a client diagnosed with peripheral arterial disease who has been taking aspirin 81 mg daily prophylactically for several months, which assessment finding is of most concern?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is ["B","D","E"]

Explanation

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Correct Answer is D

Explanation

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