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

Pedal pulses are +1 bilaterally

Complaints of burning pain during the night

Tissue that is blackened on the great toe

Answer and Explanation

The Correct Answer is C

Choice A rationale

Complaints of muscle cramps with exercise. While muscle cramps with exercise can be a symptom of peripheral arterial disease (PAD), they are more commonly associated with the earlier stages of the disease, known as intermittent claudication.

Choice B rationale

Pedal pulses are +1 bilaterally. Reduced or absent pedal pulses can be a sign of PAD, but a finding of +1 pedal pulses does not necessarily correlate with stage III of the disease.

Choice C rationale

Complaints of burning pain during the night. Stage III PAD, also known as critical limb ischemia, is characterized by more severe symptoms, including discomfort or pain in the feet or toes, even while at rest. Symptoms tend to worsen at night.

Choice D rationale

Tissue that is blackened on the great toe. This is a sign of gangrene, which is a severe and potentially life-threatening complication of PAD2. However, it is not a typical finding in stage III PAD, and would more likely be seen in the most advanced stage of the disease.

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Correct Answer is C

Explanation

Choice A rationale

The client’s fasting blood glucose level, postprandial blood glucose level, and hemoglobin A1c level are all within the target range for good blood glucose control in diabetes. Therefore, the client is not at an increased risk for developing hypoglycemia.

Choice B rationale

Insulin resistance is a characteristic of type 2 diabetes, not type 1 diabetes. The client’s blood glucose levels are well controlled, which suggests that the client’s insulin regimen is effective, not that the client is demonstrating signs of insulin resistance.

Choice C rationale

Choice D rationale

A. Obtain a full set of vital signs. B. Administer 1 mg glucagon subcutaneously. C. Administer 25 mL of 50% dextrose. D. Obtain a blood glucose reading.

Correct Answer is D

Explanation

Choice A rationale

While obtaining a full set of vital signs is an important part of assessing a patient’s condition, it should not be the initial action in this case. The symptoms described by the patient suggest hypoglycemia, which requires immediate confirmation and treatment.

Choice B rationale

Administering 1 mg glucagon subcutaneously is not the initial action. Glucagon is used to treat severe hypoglycemia when the patient is unable to take glucose orally. However, the patient’s blood glucose level should be checked first.

Choice C rationale

Administering 25 mL of 50% dextrose is not the initial action. This treatment is used for severe hypoglycemia, but the patient’s blood glucose level should be checked first to confirm hypoglycemia.

Choice D rationale

Obtaining a blood glucose reading is the correct initial action. The symptoms described by the patient suggest hypoglycemia. Checking the blood glucose level will confirm whether the patient is hypoglycemic and needs treatment.

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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?

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The client, on an intensified insulin regimen, consistently has a fasting blood glucose between 70 and 80 mg/dL, a postprandial blood glucose level below 200 mg/dL, and a hemoglobin A1c level of 5.5%. What is the nurse’s interpretation of these findings?

Correct Answer is C

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

A patient is recovering from an episode of diabetic ketoacidosis and reports feeling “anxious, shaky, and sweaty.”. What should be the nurse’s initial action?

Correct Answer is D

Explanation

Choice B rationale

Choice C rationale

Choice D rationale

A patient diagnosed with Type 1 diabetes reports a blood glucose level of 210 mg/dL and symptoms of a sore throat, cough, and fever. What advice should the nurse give to the patient?

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