The nurse is caring for a patient with a diagnosis of chronic peripheral arterial disease. Which statement by the patient warrants immediate intervention by the nurse?
“My feet look reddish when I put them down.”.
“I noticed that the hair on my feet and 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.”.
The Correct Answer is C
Choice A rationale
Reddish feet when put down could be a sign of dependent rubor, a condition that occurs due to peripheral arterial disease (PAD). When the legs are in a dependent (downward) position, gravity aids in delivering blood to the area, causing a reddish color. However, this is a common symptom of PAD and does not require immediate intervention.
Choice B rationale
Loss of hair on the feet and legs is another symptom of PAD1. This happens because inadequate blood flow deprives the hair follicles of the nutrients they need to grow. While this symptom indicates worsening PAD, it does not warrant immediate intervention.
Choice C rationale
Applying a heating pad to cold legs could lead to burns because PAD can cause loss of sensation in the legs. This warrants immediate intervention to prevent injury.
Choice D rationale
Leg pain during walking, also known as claudication, is a common symptom of PAD1. This happens because the muscles are not getting enough oxygen due to reduced blood flow.
However, this symptom does not require immediate intervention but should be evaluated further.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Intermittent claudication, which involves limb pain or cramping that generally begins when exercising and improves while resting, is a common symptom in the early stages of PAD5.
Choice B rationale
Foot ulcers are not typically a symptom of the early stages of PAD. They are more likely to occur in the later stages of the disease when blood flow to the extremities is significantly reduced.
Choice C rationale
Pain at rest is not typically a symptom of the early stages of PAD. It is more likely to occur in the later stages of the disease when blood flow to the extremities is significantly reduced.
Choice D rationale
Dependent rubor is not typically a symptom of the early stages of PAD. It is more likely to occur in the later stages of the disease when blood flow to the extremities is significantly reduced.
Correct Answer is C
Explanation
Choice A rationale
Omitted meals can lead to hypoglycemia, not diabetic ketoacidosis (DKA). DKA is caused by a lack of insulin, not a lack of food intake.
Choice B rationale
Polydipsia and polyphagia are symptoms of hyperglycemia, not causes of DKA. They occur as the body tries to compensate for high blood sugar levels.
Choice C rationale
Not taking enough insulin is a primary cause of the development of DKA. Without enough insulin, the body begins to break down fat for fuel, which produces acids known as ketones.
Choice D rationale
An insulin overdose would lead to hypoglycemia, not DKA. DKA is caused by a lack of insulin, not an excess.
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