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 ["37.5"]
Explanation
Drip rate (drops per minute) = (Volume to be infused (mL) x Drop factor) / Time (minutes)
3 hours = 3 * 60 = 180 minutes
Drip rate = (450 mL x 15 drops/mL) / 180 minutes Drip rate = 6750 / 180
Drip rate = 37.5 drops per minute
Therefore, the nurse should regulate the IV at a rate of 37.5 drops per minute.
Correct Answer is B
Explanation
A. The effectiveness of oral antihypoglycemic agents does not depend on dosage amounts that would make them cost-prohibitive. Instead, these medications work by stimulating insulin production or enhancing insulin sensitivity, which is not relevant for Type 1 diabetes.
B. While some individuals may have allergies to certain medications, this is not the reason oral antihypoglycemic agents are ineffective for those with Type 1 diabetes. The ineffectiveness is not related to allergy but rather to the underlying pathology of the disease.
C. While it is true that the risk of hypoglycemia exists with all glucose-lowering therapies, this is not the primary reason why oral antihypoglycemics are ineffective in Type 1 diabetes. The use of these agents may increase hypoglycemia risk in a broader context, but the fundamental issue is related to insulin deficiency.
D. In Type 1 diabetes, the pancreas produces little to no insulin due to autoimmune destruction of insulin-producing beta cells. Oral antihypoglycemic agents typically rely on the presence of some endogenous insulin to be effective.
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