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?
Skin cool to the touch
Healthy nail appearance
Skin warm and dry
Pulse is 2+
Leg appears swollen
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. "Leave" is not a part of the LEARN mnemonic.
B. "Leverage" is also not included in the LEARN mnemonic.
C. "Listen" is the correct answer; it encourages active listening to understand the client’s cultural needs and perspectives.
D. While "Look" may imply observation, it is not a component of the LEARN mnemonic.
E. "Liken" is not part of the LEARN mnemonic and is not relevant here.
Correct Answer is A
Explanation
A. Auscultate for any cardiac murmurs is correct, as a thrill often indicates turbulent blood flow, which may correlate with murmurs that can be heard upon auscultation.
B. Comparing apical and radial pulse rates is useful in assessing pulse deficits but does not directly address the cause of the thrill.
C. Palpating the quality of the peripheral pulses does not provide specific information about the thrill's origin.
D. Finding the point of maximal impulse is a useful cardiac assessment but does not directly explain the cause of the thrill.
E. Checking capillary refill time assesses peripheral perfusion but does not relate to the thrill's cause.