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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A reason: This is incorrect. Traveling to cities where the oxygen level is lower, such as high-altitude areas, can trigger a sickle cell crisis by reducing the amount of oxygen in the blood. People with sickle cell anemia should avoid such places or take precautions such as using supplemental oxygen¹².

Choice B reason: This is incorrect. Strenuous exercise does not prevent sickle cell crisis, but rather can cause it by increasing the body's oxygen demand and dehydration. People with sickle cell anemia should avoid overexertion and rest frequently during physical activity¹³.

Choice C reason: This is incorrect. Flying on commercial airlines is not prohibited for people with sickle cell anemia, as long as they stay hydrated and avoid alcohol and caffeine. However, some people may need to use supplemental oxygen during flights, especially if they have a history of acute chest syndrome or pulmonary hypertension¹⁴.

Choice D reason: This is correct. Drinking plenty of fluids when outside in hot weather is important for people with sickle cell anemia, as dehydration can cause the red blood cells to sickle and block blood vessels. Staying hydrated can help prevent or reduce the severity of sickle cell crises¹⁵.

A. Take a baby aspirin with a full glass of cold water at bedtime. B. You can take 81 mg of enteric coated aspirin with orange juice at lunch time. C. It's ok to take the aspirin with some ginseng tea in the evening. D. Take the aspirin with a glass of milk or food in the morning.

Correct Answer is D

Explanation

Choice A reason: Taking a baby aspirin with a full glass of cold water at bedtime is not a good discharge instruction for this client. Aspirin can increase the risk of bleeding, especially in the stomach and intestines. ¹ Taking aspirin at bedtime may increase the exposure of the GI mucosa to the drug and worsen the bleeding. ² Cold water may also irritate the stomach lining and cause discomfort.

Choice B reason: Taking 81 mg of enteric coated aspirin with orange juice at lunch time is not a good discharge instruction for this client. Enteric coated aspirin is designed to dissolve in the small intestine, not the stomach, to reduce the risk of GI bleeding. ³ However, orange juice is acidic and may damage the coating and release the aspirin in the stomach. ⁴ This may increase the bleeding and cause pain or ulcers.

Choice C reason: Taking the aspirin with some ginseng tea in the evening is not a good discharge instruction for this client. Ginseng is an herbal supplement that may interact with aspirin and increase the risk of bleeding. ⁵ Taking the aspirin in the evening may also have the same drawbacks as taking it at bedtime, as explained in choice A.

Choice D reason: Taking the aspirin with a glass of milk or food in the morning is the best discharge instruction for this client. Milk and food can help protect the stomach lining from the irritating effects of aspirin and reduce the risk of bleeding. Taking the aspirin in the morning can also minimize the exposure of the GI mucosa to the drug during the night, when the stomach is empty and more vulnerable. ²

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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