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 B
Explanation
A. S1 and S2 heard with the diaphragm of the stethoscope is a normal finding, as these are the expected heart sounds.
B. A blowing sound heard over the mitral area with the bell of the stethoscope suggests a possible murmur, which could indicate valvular abnormalities and is considered abnormal.
C. Apical pulse palpated at the 5th intercostal space, midclavicular line is normal and expected in adults.
D. Absence of sound over carotid arteries with the bell of the stethoscope indicates no bruits and is considered normal.
Correct Answer is E
Explanation
A. In asthma, increased airway resistance can lead to decreased fremitus due to air trapping and poor conduction of vibrations.
B. Emphysema results in hyperinflated lungs, which typically decreases tactile fremitus because of increased air in the alveoli.
C. Pneumothorax involves air in the pleural space, leading to decreased tactile fremitus as well, since air does not conduct vibrations well.
D. Acute bronchitis can cause some changes in fremitus, but it typically does not significantly increase it.
E. Pneumonia causes consolidation of lung tissue, which increases tactile fremitus due to enhanced transmission of vibrations through solidified lung tissue.