The nurse is caring for a client with a diagnosis of chronic peripheral arterial disease. Which statement by the client warrants immediate intervention by the nurse?
"I noticed that the hair on my feet and on my legs, is gone."
"My legs were so cold I had to put a heating pad on them."
"My legs start to hurt when I walk to get my mail."
"My feet look reddish when I put them down."
The Correct Answer is B
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. While exercise is an important aspect of diabetes management, particularly for blood glucose control and overall health, it is not the immediate priority for a newly diagnosed client. Understanding how to manage blood glucose levels is more critical initially.
B. For a client who is newly diagnosed with insulin-dependent diabetes, learning how to administer insulin is essential. This includes understanding how to prepare, inject, and store insulin, as well as recognizing the signs of hypoglycemia and hyperglycemia. Proper insulin administration is crucial for managing blood glucose levels and preventing complications.
C. Understanding dietary management is important in diabetes care, as it plays a significant role in blood sugar control. However, without knowing how to administer insulin, a client may struggle to manage their blood glucose levels effectively, making insulin administration a higher priority initially.
D. While monitoring urine for ketones is important, particularly in cases of potential diabetic ketoacidosis (DKA), this is not the first priority for a newly diagnosed client. The focus should be on fundamental skills and knowledge for managing diabetes, such as insulin administration.
Correct Answer is B
Explanation
This is the correct time to start monitoring for hypoglycemia. The insulin would have started working by this time, and the nurse can assess for any signs of low blood sugar, such as sweating, shakiness, or confusion.
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