The nurse is providing care for a client recently diagnosed with peripheral arterial occlusive disease (PAD). What assessment finding is most consistent with this diagnosis?
Visible clubbing of the fingers and toes
Unequal peripheral pulses between extremities
Reddened extremities with muscle atrophy
Loss of hair on the distal extremities
The Correct Answer is D
A. Visible clubbing of the fingers and toes
Clubbing is a condition characterized by changes in the shape and appearance of the fingers and toes. It involves enlargement of the fingertips and the nails becoming curved and rounded. Clubbing is not typically associated with peripheral arterial occlusive disease (PAD). It is more commonly seen in conditions such as chronic respiratory or cardiovascular diseases.
B. Unequal peripheral pulses between extremities
Unequal peripheral pulses can be indicative of vascular abnormalities. However, in PAD, the characteristic finding is diminished or absent pulses rather than unequal pulses between extremities. Other conditions, such as arterial embolism or thrombosis, may present with unequal pulses.
C. Reddened extremities with muscle atrophy
Reddened extremities and muscle atrophy are not typical findings in PAD. These symptoms are more characteristic of conditions associated with chronic inflammation or compromised venous circulation, such as chronic venous insufficiency or venous stasis.
D. Loss of hair on the distal extremities
Loss of hair on the distal extremities, particularly on the lower legs and feet, is a common finding in PAD. It results from reduced blood flow and oxygen supply to the hair follicles in the affected areas.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. The client now has developed a myocardial infarction:
A myocardial infarction (heart attack) is characterized by prolonged ischemia leading to damage or death of heart muscle cells. While the symptoms described could be concerning for a heart attack, the term "myocardial infarction" would typically imply a more sustained and severe ischemic event.
B. The client has developed Prinzmetal's angina:
Prinzmetal's angina, also known as variant angina, is characterized by chest pain that usually occurs at rest and is caused by vasospasm of the coronary arteries. The given scenario does not specifically describe the typical characteristics of Prinzmetal's angina.
C. The client now has stable angina:
Stable angina typically follows a predictable pattern and is relieved with rest and/or nitroglycerin. However, the scenario describes a change in the usual pattern of chest pain.
D. The client now has unstable angina:
Unstable angina is characterized by a change in the usual pattern of stable angina, often occurring at rest or with minimal exertion and not relieved by usual measures. This option seems to align with the information provided.
Correct Answer is ["50"]
Explanation
To calculate the drops per minute for the ondansetron infusion, we need to use the formula:
drops per minute = (volume in mL x drop factor) / time in minutes
In this case, the volume is 50 mL, the drop factor is 15 gtt/mL, and the time is 15 minutes. Plugging these values into the formula, we get:
drops per minute = (50 x 15) / 15
drops per minute = 750 / 15
drops per minute = 50
Therefore, the nurse should set the infusion pump to deliver 50 drops per minute of ondansetron to the client with severe nausea.
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