In assessing a client with skin ulcers on the lower extremity, which findings indicate that the ulcers are likely to be of venous, rather than arterial, origin?

Absent pedal pulses and shiny skin.

Irregular ulcer shapes and severe edema.

Hairless lower extremities and cool feet.

Black ulcers and dependent rubor.

Answer and Explanation

The Correct Answer is B

B. Severe edema is a common finding in venous insufficiency and is often present in the lower extremities. Venous hypertension leads to fluid leakage from capillaries, resulting in edema, which contributes to the development of venous ulcers. Venous ulcers typically have irregular shapes with irregular wound margins and may appear shallow or superficial.
A. Absent pedal pulses suggest arterial insufficiency, as reduced blood flow compromises peripheral circulation. Shiny skin, known as "thinning of the skin," is a characteristic finding in arterial insufficiency due to chronic ischemia and tissue hypoxia.
C. Hair loss on the lower extremities is a common finding in arterial insufficiency due to decreased blood flow to the hair follicles.
D. Black ulcers (gangrene) are indicative of tissue necrosis resulting from severe arterial insufficiency and lack of oxygen supply to the tissues. Dependent rubor refers to redness of the lower extremities when the legs are in a dependent position.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

A. A high-pitched sound heard upon inspiration, known as a "stridor," can indicate airway obstruction or respiratory distress. In the postoperative period following an appendectomy, airway patency and adequate ventilation are essential for the client's oxygenation and recovery.
B. While a slightly elevated heart rate may be expected in the immediate postoperative period due to stress or pain, it does not typically require immediate action unless accompanied by other concerning symptoms.
C. Redness and edema at the incision site can be normal inflammatory responses following surgery.
D. Pain is common after surgery, and a pain rating of 8 on a scale of 0 to 10 indicates moderate to severe pain.

A. Meningococcal meningitis. B. Cerebrovascular accident (CVA). C. Intracerebral hemorrhage. D. Rocky mountain spotted fever.

Correct Answer is A

Explanation

A. Meningococcal meningitis is a bacterial infection of the meninges (the protective membranes covering the brain and spinal cord) caused by the bacterium Neisseria meningitidis. It is characterized by symptoms such as severe headache, fever, nuchal rigidity (stiff neck), and a petechial rash on the skin. The petechial rash is a distinguishing feature of meningococcal meningitis and is caused by bleeding into the skin due to disseminated intravascular coagulation (DIC) associated with the infection.
B. A cerebrovascular accident, commonly known as a stroke, occurs when blood flow to a part of the brain is interrupted, leading to tissue damage and neurological deficits. While a stroke can cause symptoms such as headache and neurological deficits, it typically does not present with fever, nuchal rigidity, or a petechial rash.

C. Intracerebral hemorrhage is bleeding within the brain tissue, often due to the rupture of a blood vessel. It can cause symptoms such as headache, neurological deficits, and alterations in consciousness, but it typically does not present with fever, nuchal rigidity, or a petechial rash.
D. Rocky mountain spotted fever (RMSF) is a bacterial infection caused by the bacterium. While RMSF can present with fever and rash, it typically does not present with nuchal rigidity, and the petechial rash associated with RMSF tends to start on the extremities rather than the arms and legs.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

In assessing a client with skin ulcers on the lower extremity, which findings indicate that the ulcers are likely to be of venous, rather than arterial, origin?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who had an appendectomy 4 hours ago. Which finding requires immediate action by the nurse?

Correct Answer is A

Explanation

A client presents with the onset of a severe headache, fever, nuchal rigidity, and a petechial rash on arms and legs. The nurse recognizes the client is exhibiting symptoms of which condition?

Correct Answer is A

Explanation

A client who had a biliopancreatic diversion procedure (BDP) 3 months ago is admitted with severe dehydration. Which assessment finding warrants immediate intervention by the nurse?

A client with a right ulnar fracture and cast placement reports an increase in arm pain. Which action should the nurse take next?

A family suspects that AIDS dementia is occurring in their adult child who is HIV positive. Which symptom confirms the suspicion?

While assisting a client to the toilet, the client begins to have a seizure and the nurse eases the client to the floor. The nurse calls for help and monitors the client until the seizing stops. Which intervention should the nurse implement first?

In assessing a client with skin ulcers on the lower extremity, which findings indicate that the ulcers are likely to be of venous, rather than arterial, origin?

A client with draining skin lesions of the lower extremity is admitted with possible methicillin resistant Staphylococcus aureus (MRSA). What nursing intervention (s) should the nurse include in the plan of care? Select all that apply.

Five months following treatment for herpes zoster, an older adult client tells the home health nurse of continuing to experience pain where the rash occurred. Which action should the nurse implement?

A client with metastatic cancer reports a pain level of 10 on a scale of 0 to 10. Twenty minutes after the nurse administers an IV analgesic, the client reports no pain relief. Which intervention is most important for the nurse to include in this client's plan of care?