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A client has been diagnosed with peripheral arterial insufficiency to the right leg. Which of these findings would the nurse expect to find with this condition?

A.

Skin cool to the touch

B.

Healthy nail appearance

C.

Skin warm and dry

D.

Pulse is 2+

E.

Leg appears swollen

Answer and Explanation

The Correct Answer is A

A. In peripheral arterial insufficiency, blood flow is reduced, leading to cooler skin temperatures, especially in the affected extremity.

 

B. Nail appearance may be unhealthy due to poor perfusion; nails may become thickened or grow slowly.

 

C. Skin is typically cool and may be dry, not warm, indicating reduced blood flow.

 

D. A pulse of 2+ is within normal range; however, pulses may be diminished or absent in cases of significant arterial insufficiency.

 

E. The leg typically does not appear swollen; rather, it may show signs of atrophy or hair loss due to inadequate blood supply.


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Correct Answer is C

Explanation

A. Supine is not recommended, as it can make breathing more difficult by limiting chest expansion.

B. Trendelenberg is not suitable for someone with breathing difficulties, as this position can worsen dyspnea.

C. High-Fowler is the best position for an asthma patient experiencing shortness of breath as it promotes lung expansion and allows for maximum chest wall movement.

D. Semi-Fowler may help but is less effective than High-Fowler in cases of acute respiratory distress.

E. Left-lateral does not optimize chest expansion and is not typically recommended for respiratory distress.

Correct Answer is E

Explanation

A. Music can be a soothing nonpharmacologic method to reduce pain and may help with relaxation, even for confused patients, as it typically doesn’t require cognitive engagement.

B. Aromatherapy is generally safe and may offer calming effects for older adults without relying heavily on cognitive processing.

C. Heat application is a physical pain relief method, and as long as safety precautions are taken, it can be used effectively in confused patients.

D. Distraction can be a beneficial technique for pain relief and is often effective without requiring cognitive engagement.

E. Guided Imagery should be avoided in confused older adults, as it relies on the patient's ability to follow instructions and visualize mental images, which can be challenging and potentially frustrating for someone with cognitive impairment.

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