A client is admitted with a venous insufficiency of the right leg. What assessment findings does the nurse expect to find with this condition?
Poor hair growth
Weak pulse
Edema
Calf muscle atrophy (shrinkage)
Pale color
The Correct Answer is C
A. Poor hair growth is more associated with arterial insufficiency.
B. A weak pulse may suggest arterial, not venous, insufficiency.
C. Edema is a common finding in venous insufficiency due to fluid pooling in the extremities.
D. Muscle atrophy is not typically associated with venous insufficiency.
E. Pale color is more indicative of arterial insufficiency, while venous insufficiency may present with darkened or reddish skin.
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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 B
Explanation
A. Decreased lung sounds on expiration are common in COPD patients due to airway obstruction but do not necessarily indicate an acute issue.
B. Respirations are 40 breaths/minute is a critical finding, as this rapid respiratory rate suggests significant respiratory distress or worsening hypoxemia, which needs immediate intervention to prevent further complications.
C. An anterior-posterior diameter ratio of 1:1 (barrel chest) is a common finding in advanced COPD but does not indicate acute worsening.
D. Hyperresonance to percussion is typical in patients with COPD due to air trapping and does not suggest an immediate emergency.
E. Decreased tactile fremitus may occur in COPD due to increased air trapping but is not an urgent finding requiring immediate reporting.