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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is Choice A. Insulin lispro is a fast-acting insulin that starts to work about 15 minutes after injection. Therefore, the client should eat within 15 minutes of taking the insulin to prevent hypoglycemia. So, if the client takes the insulin at 0630, they should start eating at 06404
Correct Answer is A
Explanation
Choice A rationale
Consuming excessive amounts of antacids, such as TUMS, can lead to metabolic alkalosis. Antacids contain bicarbonate, which can neutralize stomach acid. However, excessive bicarbonate in the body can disrupt the acid-base balance, leading to metabolic alkalosis.
Choice B rationale
Respiratory acidosis is typically caused by conditions that result in hypoventilation, such as lung diseases or drug overdose, not by excessive antacid consumption.
Choice C rationale
Metabolic acidosis is typically caused by conditions that increase acid in the body or decrease bicarbonate, such as kidney disease or lactic acidosis, not by excessive antacid consumption.
Choice D rationale
Respiratory alkalosis is typically caused by conditions that result in hyperventilation, such as anxiety or fever, not by excessive antacid consumption.
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