A nurse is assessing client with advanced peripheral arterial disease (PAD). Which of the following findings would the nurse expect?
Shiny, hairless lower extremities.
Warm lower extremities.
Thin toenails.
Lower extremity bilateral pulse 3+
The Correct Answer is A
A) Shiny, hairless lower extremities: In advanced peripheral arterial disease (PAD), the skin on the lower extremities often appears shiny and hairless due to reduced blood flow. The lack of hair growth and the shiny appearance are indicative of ischemia and poor circulation, making this a common finding in clients with advanced PAD.
B) Warm lower extremities: This finding is not typical in advanced PAD. Due to compromised blood flow, the lower extremities are more likely to feel cool or cold to the touch rather than warm. Warm skin can indicate good blood flow, which is usually absent in cases of significant arterial disease.
C) Thin toenails: In advanced PAD, toenails may become thin and brittle due to insufficient blood supply, which can lead to impaired nail growth. This change is consistent with the overall effects of reduced circulation and is an expected finding in clients with advanced PAD.
D) Lower extremity bilateral pulse 3+: A 3+ pulse indicates a strong and bounding pulse, which is not typically present in advanced PAD. In fact, patients with PAD often exhibit diminished or absent pulses in the affected extremities due to poor arterial circulation. Therefore, this finding does not align with the expected assessment results for advanced PAD.
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Correct Answer is C
Explanation
A) Ventricular tachycardia: Ventricular tachycardia is characterized by a rapid heart rate exceeding 100 bpm, typically arising from abnormal ventricular activity. In this case, the heart rate is 59 bpm, which does not support this interpretation. Additionally, ventricular tachycardia usually presents with wide QRS complexes and no discernible P waves, neither of which is true in this scenario.
B) Sinus tachycardia: Sinus tachycardia is defined by a heart rate exceeding 100 bpm originating from the sinoatrial (SA) node, with a regular rhythm and normal P waves. The heart rate of 59 bpm in this client is too low for a diagnosis of sinus tachycardia, making this option incorrect.
C) Sinus bradycardia: Sinus bradycardia occurs when the heart rate is less than 60 bpm, with a regular rhythm and a normal PR interval and QRS duration. The provided data shows a heart rate of 59 bpm, a regular rhythm, one P wave for every QRS complex, a PR interval of 0.20 seconds, and a QRS duration of 0.10 seconds, which aligns perfectly with the criteria for sinus bradycardia.
D) Normal sinus rhythm: Normal sinus rhythm typically presents with a heart rate of 60-100 bpm, a regular rhythm, and appropriate P waves for each QRS complex. Given the heart rate of 59 bpm, this does not meet the criteria for normal sinus rhythm, as it falls below the acceptable range.
Correct Answer is A
Explanation
A. "Diuretics are the first line therapy to control hypertension.": This statement is accurate. Thiazide diuretics are commonly recommended as first-line treatment for mild hypertension, as they help reduce blood volume and lower blood pressure effectively.
B. "Reaching your goal blood pressure will occur within 2 months.": While treatment can lead to improvements in blood pressure, the timeline for reaching target levels can vary significantly among individuals based on adherence to lifestyle changes and medication. It's important to communicate that achieving the goal may take longer than two months.
C. "Plan to add saturated fats to 10 percent of your daily calorie intake.": This recommendation is misleading. Guidelines generally suggest limiting saturated fats to less than 10 percent of total daily calories to promote heart health, not adding them.
D. "Limit your alcohol consumption to three drinks a day.": This statement is also inaccurate. For most adults, the recommendation is to limit alcohol to no more than two drinks per day for men and one drink per day for women to help manage blood pressure effectively.