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 ["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.
Correct Answer is D
Explanation
A. Intake and output:
Intake and output refer to monitoring the amount of fluids a person consumes (intake) and eliminates (output) through urine, feces, and other means. While tracking fluid intake and output is important, it may not provide a direct indication of excess fluid retention.
B. Pitting pedal edema:
Pitting pedal edema is swelling in the lower extremities, particularly the ankles and feet, that leaves an indentation (pit) when pressure is applied. This can be a sign of fluid retention but may not always be the earliest or most reliable indicator.
C. Crackles in the bases of the lungs:
Crackles or rales in the bases of the lungs can be indicative of pulmonary congestion, which may occur due to fluid accumulation. However, crackles alone may not always be specific to fluid overload and can be present in other respiratory conditions.
D. Daily weights:
Daily weights are a critical and sensitive measure for assessing fluid balance. Sudden weight gain, especially over a short period, can be a strong indicator of fluid retention. Monitoring weight on a daily basis helps to detect changes early, allowing for prompt intervention.
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