The nurse, who is assessing a client with peripheral vascular disease, notes that the client has no hair on the legs and has thick toenails. Which statement describes the cause of this finding?
Decreased hair is most likely a hereditary condition and nail changes are related to fungus.
A blood clot may be forming and the client needs immediate intervention.
Decreased oxygen to the tissues causes changes in hair growth and nail texture.
Depending on the client's age, the findings may be normal.
The Correct Answer is D
Choice A reason: Decreased hair is most likely a hereditary condition and nail changes are related to fungus is not the statement that describes the cause of this finding. This statement is not based on evidence and does not explain the relationship between peripheral vascular disease and the observed changes in the legs and feet.
Choice B reason: A blood clot may be forming and the client needs immediate intervention is not the statement that describes the cause of this finding. This statement is an alarmist and inaccurate interpretation of the finding. A blood clot would cause more acute and severe symptoms, such as pain, swelling, redness, and warmth in the affected area.
Choice C reason: Decreased oxygen to the tissues causes changes in hair growth and nail texture is the statement that describes the cause of this finding. This statement is based on the pathophysiology of peripheral vascular disease, which is a chronic condition that reduces the blood flow to the extremities due to atherosclerosis or inflammation of the blood vessels. The reduced blood flow leads to tissue ischemia and necrosis, which can manifest as hair loss, thickening and yellowing of the nails, skin ulcers, and gangrene.
Choice D reason: Depending on the client's age, the findings may be normal is not the statement that describes the cause of this finding. This statement is a vague and dismissive response that does not address the underlying problem of peripheral vascular disease. The findings are not normal for any age group and require further assessment and intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: A history of cardiac disease is not directly related to enlarged axillary lymph nodes. Cardiac disease may affect the heart, blood vessels, and circulation, but not the lymphatic system. ¹
Choice B reason: A recent infection is a possible cause of enlarged axillary lymph nodes. Lymph nodes are part of the immune system and they swell when they are fighting an infection. ² The nurse should ask the client about any signs or symptoms of infection, such as fever, sore throat, or skin rash.
Choice C reason: Shortness of breath is not directly related to enlarged axillary lymph nodes. Shortness of breath may indicate a respiratory problem, such as asthma, bronchitis, or pneumonia. ³ However, these conditions do not usually affect the lymph nodes in the armpit area.
Choice D reason: Surgery on the neck is not directly related to enlarged axillary lymph nodes. Surgery on the neck may affect the lymph nodes in the neck or the collarbone area, but not the lymph nodes in the armpit area. The nurse should ask the client about any history of surgery or trauma to the lymph nodes or the surrounding tissues.
Correct Answer is D
Explanation
Choice A reason: Increasing calcium in the diet is not the most important instruction for a client with hypertension. Calcium is a mineral that helps maintain bone health and muscle contraction, but it does not have a significant effect on blood pressure. The nurse should advise the client to limit sodium, fat, and alcohol intake, and to eat more fruits, vegetables, and whole grains.
Choice B reason: Obtaining blood pressure checks twice a year is not the most important instruction for a client with hypertension. This frequency is too low for a client who has a chronic condition that requires close monitoring and treatment. The nurse should advise the client to check their blood pressure regularly, preferably at home, and to report any abnormal readings to their health care provider.
Choice C reason: Monitoring weight on a weekly basis is not the most important instruction for a client with hypertension. Weight is a factor that can influence blood pressure, but it is not the only one. The nurse should advise the client to maintain a healthy weight and to lose weight if they are overweight or obese, but not to focus on the scale alone.
Choice D reason: Getting regular physical activity is the most important instruction for a client with hypertension. Physical activity can lower blood pressure by strengthening the heart, improving blood circulation, reducing stress, and preventing or managing other risk factors, such as obesity, diabetes, and high cholesterol. The nurse should advise the client to engage in moderate aerobic exercise for at least 30 minutes a day, five days a week, and to consult their health care provider before starting any new exercise program.
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