The client's chart indicates the diagnosis of stage III peripheral arterial disease. Which nursing assessment finding correlates with this diagnosis?
Complaints of muscle cramps with exercise
Complaints of burning pain during the night
Pedal pulses are +1 bilaterally
Tissue that is blackened on the great toe
The Correct Answer is B
A. While claudication (muscle cramps with exercise) is common in earlier stages of PAD, it typically occurs in stage II. In stage III, pain often occurs at rest rather than with exertion.
B. In stage III PAD, patients often report rest pain, which can manifest as burning pain in the legs or feet, particularly at night when lying down. This is a hallmark symptom of advanced PAD due to inadequate blood flow.
C. While diminished pulses (like +1) can be found in PAD, this finding alone is not specific to stage III. In advanced stages, pulses may be even weaker or absent.
D. Blackened tissue (necrosis or gangrene) indicates a more severe stage (stage IV) of PAD, where there is critical limb ischemia and tissue death due to a lack of blood flow. Stage III may involve severe pain but usually does not have necrosis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D","E"]
Explanation
A. Tamsulosin primarily affects urinary function and is not directly related to glucose metabolism or insulin action. It does not significantly contribute to hypoglycemic events.
B. While urinary retention can lead to discomfort and potential complications, it does not have a direct impact on blood glucose levels or increase the risk of hypoglycemia. However, if it results in increased stress or medication changes, it could indirectly affect glucose management.
C. Physical activity, such as jogging, can increase the risk of hypoglycemia in individuals with Type 1 diabetes, especially if they do not adjust their insulin or carbohydrate intake accordingly. Exercise can enhance insulin sensitivity and cause blood glucose levels to drop.
D. Alcohol can increase the risk of hypoglycemia, particularly in individuals with diabetes, because it can inhibit gluconeogenesis (the liver's ability to produce glucose). Drinking a significant amount of alcohol, especially without food, can lead to dangerously low blood sugar levels.
E. Metoprolol, a beta-blocker, can mask the symptoms of hypoglycemia (such as increased heart rate and tremors), making it more difficult for the individual to recognize when they are hypoglycemic. This can lead to delayed treatment and increased risk of severe hypoglycemia.
Correct Answer is ["C","D","E"]
Explanation
A. Clients on warfarin should generally avoid nonsteroidal anti-inflammatory drugs (NSAIDs) like aspirin and ibuprofen, as these can increase the risk of bleeding. Instead, acetaminophen is often recommended for pain relief, but it should be used cautiously and under a healthcare provider’s guidance.
B. While vitamin K found in green, leafy vegetables can affect warfarin levels, clients do not need to eliminate these foods entirely. Instead, they should maintain a consistent intake of vitamin K-rich foods to help manage their INR levels. Sudden changes in diet can lead to fluctuations in anticoagulation control.
C. It is important for clients taking warfarin to wear a medical alert bracelet. This alerts healthcare providers in case of an emergency, as the client may require special care due to their anticoagulant therapy.
D. Using an electric razor is a safer option for clients on warfarin as it reduces the risk of cuts and bleeding compared to using a traditional razor. This is an important safety measure for those on anticoagulation therapy.
E. Monitoring prothrombin time (PT) and International Normalized Ratio (INR) is essential for clients on warfarin to ensure they are within the therapeutic range. Regular testing helps to manage the dosage effectively and minimize the risk of bleeding or thrombosis.
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