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

Answer and Explanation

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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Correct Answer is B

Explanation

A. Loss of hair on the lower extremities can be a common sign of chronic PAD, indicating reduced blood
flow. While it’s an important observation, it is not an immediate concern.
B. Cold legs can indicate poor blood flow, which is a significant concern in PAD. The use of a heating pad can pose a risk of burns due to impaired sensation, especially in clients with poor circulation. This statement warrants immediate intervention, as the nurse should educate the client against using heat sources that can cause injury and assess the client's circulation and potential complications.
C. This describes claudication, a common symptom of PAD, where pain occurs in the legs due to inadequate blood flow during physical activity. While it indicates worsening symptoms of PAD, it is not an immediate emergency.
D. Reddish discoloration (rubor) when the legs are dependent can indicate blood pooling due to decreased venous return or arterial insufficiency. While this observation is significant and requires monitoring, it is not as urgent as the concern related to using a heating pad.

A. Continue walking to the point of pain B. Do not walk if a leg ulcer develops C. Elevate the feet for 30 minutes after walking D. Avoid exercise that places the feet in a dependent position

Correct Answer is A

Explanation

A. Clients with PAD often experience claudication (pain in the legs due to inadequate blood flow) during exercise. They should be encouraged to walk to the point of pain, then rest until the pain subsides, and then continue walking. This approach can improve circulation over time.
B. While it’s crucial to monitor leg ulcers, exercise can still be beneficial unless advised otherwise by a healthcare provider. Walking can promote circulation, which is important for healing. However, if a leg ulcer is present, the client should consult their healthcare provider about appropriate activity levels.
C. While elevating the feet can help reduce swelling, it's generally more beneficial for clients with PAD to keep their legs in a dependent position after walking. This position encourages blood flow to the legs, which can help alleviate symptoms and improve circulation.
D. Exercise that encourages movement and maintains blood flow to the legs is important for those with PAD. While certain positions may exacerbate symptoms, exercises like walking should be encouraged. Keeping the feet in a dependent position can help with blood flow post-exercise.

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The client's chart indicates the diagnosis of stage III peripheral arterial disease. Which nursing assessment finding correlates with this diagnosis?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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