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.
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Related Questions
Correct Answer is D
Explanation
A. This time falls shortly after the onset of NPH insulin. While hypoglycemia could start to occur around this time, it is less likely to be at its peak.
B. This time is past the peak range of NPH insulin. The likelihood of hypoglycemia is lower as the insulin effect would be tapering off.
C. This time is well past the usual duration of NPH insulin. By this point, the risk of hypoglycemia would be significantly decreased.
D. This time falls within the peak action of NPH insulin (approximately 4-12 hours post-administration). This is when hypoglycemia is most likely to occur due to the greatest effect of the insulin.
Correct Answer is A
Explanation
A. The client's fasting blood glucose levels (70-80 mg/dl) are within the normal range, and a post- prandial blood glucose level below 200 mg/dl is also considered well-controlled, particularly for someone on an intensified insulin regimen. The hemoglobin A1c level of 4.5% indicates excellent long- term glucose control, typically representing average blood glucose levels of around 90 mg/dl.
B. Hyperglycemia is characterized by elevated blood glucose levels. Given the client's consistently normal fasting and post-prandial levels, they are not at an increased risk for hyperglycemia. Instead, they are maintaining their glucose levels well.
C. Insulin resistance typically manifests as elevated blood glucose levels despite adequate insulin levels or increased insulin requirements. In this case, the client's blood glucose levels are well-controlled, indicating that they are likely responding well to insulin therapy and are not showing signs of insulin resistance.
D. While the client’s blood glucose levels are well-controlled, the risk for hypoglycemia depends on various factors, including insulin dosage, timing, and food intake. However, consistently normal levels do not directly indicate a risk for hypoglycemia unless insulin doses are excessively high or meals are skipped. Therefore, this choice is not justified given the data provided.
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