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
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
While repositioning the limb and reassessing might be a part of the overall evaluation, it should not be the immediate action. The symptoms described are indicative of a serious issue that requires immediate medical attention.
Choice B rationale
Applying a warm blanket will not address the underlying issue. The symptoms described suggest a problem with circulation that needs immediate medical attention.
Choice C rationale
Notifying the healthcare provider is the correct immediate action. The symptoms described suggest that the patient may be experiencing a complication such as occlusion of the stent. This is a medical emergency that requires immediate intervention.
Choice D rationale
Elevating the extremity on a pillow is not the immediate action to take. While elevation can help with conditions like edema, it does not address the serious symptoms the patient is experiencing.
Correct Answer is A
Explanation
Choice A rationale
Raynaud’s disease is a condition that affects blood flow to the extremities, including the fingers and toes, in response to cold temperatures or stress. Wearing heavy-duty gloves during cold exposures can help to keep the hands warm and reduce the risk of a Raynaud’s attack.
Choice B rationale
While avoiding cold temperatures can help to prevent Raynaud’s attacks, it is not always practical or possible for individuals to refrain from going outdoors during the winter months.
Choice C rationale
Raising the hands above the head is not typically recommended to relieve spasms associated with Raynaud’s disease.
Choice D rationale
Using small rubber balls to exercise the hands and fingers daily may be beneficial for some individuals with Raynaud’s disease, but it is not typically the primary recommendation for managing this condition.
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