In assessing a client with ulcers on the lower extremity, which findings indicate that the ulcers are likely to be of venous, rather than arterial, origin?
Irregular ulcer shapes and severe edema.
Hairless lower extremities and cool feet.
Black ulcers and dependent rubor.
Absent pedal pulses and shiny skin.
The Correct Answer is A
Choice A reason: Irregular ulcer shapes and severe edema are characteristic of venous ulcers, which are caused by impaired venous return and increased capillary pressure. Venous ulcers are usually located near the medial malleolus and have a shallow depth.
Choice B reason: Hairless lower extremities and cool feet are signs of arterial insufficiency, which reduces blood flow and oxygen delivery to the tissues. Arterial ulcers are usually located on the toes, heels, or lateral malleoli and have a deep, punched-out appearance.
Choice C reason: Black ulcers and dependent rubor are also signs of arterial insufficiency, indicating tissue necrosis and inflammation. Dependent rubor is a reddish-blue color of the lower extremity that occurs when the leg is lowered below the level of the heart.
Choice D reason: Absent pedal pulses and shiny skin are also signs of arterial insufficiency, indicating reduced blood flow and atrophy of the skin. The skin may also be dry, scaly, or cracked.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"B"}}
Explanation
a) Denies cramps, weakness, or nausea
This finding indicates that the actions taken were effective in relieving the patient's symptoms of fatigue, weakness, muscle cramps, and nausea. These symptoms may have been caused by electrolyte imbalances, dehydration, or infection related to her ESRD and missed dialysis sessions.
b) BP 116/68 mm Hg, HR 75 bpm
This finding indicates that the actions taken were effective in lowering the patient's blood pressure and heart rate. The patient had a history of HTN and CAD and presented with elevated BP and HR in the ED. The orders for EKG, cardiac monitor, chest X-ray, and echocardiogram may have helped to assess and manage her cardiac status. The patient may have also received antihypertensive medications or fluids as part of her treatment.
c) Potassium level 3.6 mEq/L (3.6 mmol/L)
This finding indicates that the actions taken were effective in normalizing the patient's potassium level. The patient had ESRD and missed dialysis sessions, which could have resulted in hyperkalemia or hypokalemia. The orders for basic metabolic panel and blood cultures may have helped to monitor and correct her electrolyte levels. The patient may have also received potassium supplements or binders as part of her treatment.
d) Verbalizes commitment to dialysis appointments
This finding indicates that the actions taken were effective in educating and motivating the patient to adhere to her dialysis schedule. The patient had ESRD and missed dialysis sessions, which could have worsened her condition and increased her risk of complications. The orders for CT scan of abdomen and echocardiogram may have helped to evaluate her renal function and cardiac function. The patient may have also received counseling or support from the health care team as part of her treatment.
e) Client states that she will need to resume her Lisinopril to control blood pressure
This finding indicates that the actions taken were ineffective in teaching the patient about her medication regimen. The patient had a history of HTN and CAD and was prescribed Lisinopril as an antihypertensive medication. However, Lisinopril is contraindicated in patients with ESRD as it can cause hyperkalemia or worsen renal function. The patient should be informed about the potential risks of taking Lisinopril and advised to consult with her nephrologist or primary care provider before resuming it.
f) Client is eager to add dark green vegetables and potatoes to her diet
This finding indicates that the actions taken were ineffective in educating the patient about her dietary restrictions. The patient had ESRD and required hemodialysis three times a week. She should follow a renal diet that limits the intake of potassium, phosphorus, sodium, and fluid. Dark green vegetables and potatoes are high in potassium and phosphorus and should be avoided or consumed in moderation by patients with ESRD. The patient should be provided with a list of foods that are suitable for her condition and referred to a dietitian for further guidance.
Correct Answer is C
Explanation
Choice A reason: This is incorrect because sleeping with the head ofthe bed flat can worsen OSA by allowing gravity to pull down on the soft tissues ofthe throat and obstructing airflow.
Choice B reason: This is incorrect because taking sedatives prior to sleep can also worsen OSA by relaxing the muscles ofthe upper airway and increasing airway collapse.
Choice C reason: This is correct because beginning a weight loss program can help reduce OSA by decreasing fat deposits around the neck and chest that can compress and narrow the airway.
Choice D reason: This is incorrect because drinking 1to 2 glasses of wine at bedtime can have similar effects as sedatives, such as relaxing the muscles ofthe upper airway and impairing the respiratory drive.
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