The nurse refers an older adult client for further evaluation after the nurse assesses warm skin and brown pigmentation around the ankles. The nurse suspects which of the following?
Dependent edema
Stasis ulceration
Arterial occlusion
Venous insufficiency
The Correct Answer is D
A. Dependent edema is characterized by swelling in the lower extremities due to gravity and may not always present with pigmentation changes.
B. Stasis ulceration involves ulcerative lesions typically occurring on the lower legs, often associated with venous insufficiency, but the pigmentation alone does not confirm ulceration.
C. Arterial occlusion typically presents with symptoms such as pain, pallor, and decreased pulses, not necessarily with warm skin and brown pigmentation.
D. Venous insufficiency is characterized by symptoms such as warm skin, brown pigmentation around the ankles (due to hemosiderin deposition from blood pooling), and swelling.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Increased jugular venous pressure: Right-sided heart failure often leads to increased jugular venous pressure due to the backup of blood in the systemic venous system.
B. Decreased right-sided volume: Right-sided heart failure typically results in increased blood volume in the right heart chambers, not decreased.
C. Decreased stroke volume: While right-sided heart failure can affect stroke volume, increased jugular venous pressure is a more direct indicator of right-sided heart failure.
D. Decreased central venous pressure: Right-sided heart failure usually results in increased, not decreased, central venous pressure.
Correct Answer is A
Explanation
A. Posterior tibial: The posterior tibial pulse is palpated just behind the medial malleolus of the ankle, near the Achilles tendon.
B. Femoral: The femoral pulse is located in the groin area, where the femoral artery passes.
C. Popliteal: The popliteal pulse is palpated behind the knee in the popliteal fossa.
D. Dorsalis pedis: The dorsalis pedis pulse is located on the top of the foot, near the first metatarsal.
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