The nurse is assessing the peripheral vascular system of a client.
On inspection, the client's legs are cold and the client reports she no longer has hair growing on the legs.
What does the nurse suspect the client is experiencing?
DVT.
Venous insufficiency.
Varicosities.
Arterial insufficiency.
The Correct Answer is D
Choice A rationale
Deep vein thrombosis (DVT) involves a blood clot in a deep vein, usually in the legs. Symptoms include swelling, pain, and redness, but not typically cold legs or hair loss, making it unlikely in this scenario.
Choice B rationale
Venous insufficiency occurs when veins struggle to send blood back to the heart, leading to varicose veins, swelling, and skin changes. While it can cause leg discomfort, it does not typically result in cold legs or hair loss.
Choice C rationale
Varicosities are enlarged, twisted veins caused by increased pressure. They can cause pain and swelling but not cold legs or hair loss, making them an unlikely cause of the described symptoms.
Choice D rationale
Arterial insufficiency, caused by poor blood flow due to narrowed arteries, results in symptoms such as cold legs, hair loss, pain, and weakened pulses. The description of cold legs and hair loss fits arterial insufficiency, making it the most likely diagnosis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C"]
Explanation
Choice A rationale
An elliptical chest configuration is considered a normal shape for the thorax. This configuration allows for optimal lung expansion and function. Deviations from this shape, such as a barrel chest, might indicate underlying pulmonary conditions.
Choice B rationale
Eupnea refers to normal, unlabored breathing, which is an expected finding during a respiratory assessment. It indicates that the individual is not experiencing respiratory distress and that their respiratory rate, rhythm, and effort are within normal limits.
Choice C rationale
Resonance is a normal percussion sound heard over healthy lung tissue. It indicates that the underlying lung areas are filled with air, which is a positive sign of healthy lung function.
Choice D rationale
Inspiratory wheezing, a high-pitched whistling sound during breathing, is typically indicative of narrowed or obstructed airways, often associated with conditions such as asthma or chronic obstructive pulmonary disease, and is not considered a normal finding.
Correct Answer is B
Explanation
Choice A rationale
Lateralization to the unaffected ear in Weber's test actually indicates sensorineural hearing loss in the affected ear. This choice is incorrect as it doesn’t describe the correct procedure for the test.
Choice B rationale
The Weber's test involves placing an activated tuning fork in the midline of the skull and asking the patient if the sound is heard more loudly in either ear. This helps determine if there is lateralization, which is key in diagnosing the type of hearing loss. Thus, this is the correct procedure for the test.
Choice C rationale
Placing the tuning fork on the mastoid bone and then over air is actually part of the Rinne test, not the Weber test. This choice is, therefore, incorrect for the Weber test.
Choice D rationale
Similar to Choice C, this process describes the Rinne test, which compares air conduction and bone conduction of sound. This is not the correct method for performing Weber’s test.
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