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 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.
Correct Answer is ["A","B"]
Explanation
A. Inquiring about personal and family cardiac history provides essential subjective information on potential hereditary risks and the client’s own cardiac health.
B. Asking about fatigue and chest pain allows the nurse to assess symptoms that may suggest cardiac issues, making it critical subjective data.
C. Inspecting for intercostal retractions and nasal flaring is part of the objective assessment rather than subjective data.
D. Palpating the chest for thrills and heaves is also an objective action, assessing physical findings rather than subjective symptoms.
E. Auscultating the heart with the diaphragm and bell of the stethoscope is an objective assessment to detect sounds rather than gathering subjective information from the client.