A nurse is collecting data from a client who has peripheral arterial disease (PAD). Which of the following findings should the nurse expect?
Warm extremities.
Darkened skin color near extremities.
Intermittent claudication.
Edema.
The Correct Answer is C
Choice A rationale
Warm extremities are not typically associated with peripheral arterial disease (PAD). PAD usually results in reduced blood flow, leading to cooler extremities.
Choice B rationale
Darkened skin color near extremities is more commonly associated with venous insufficiency rather than PAD. PAD typically causes pale or bluish skin due to reduced blood flow.
Choice C rationale
Intermittent claudication, which is pain or cramping in the legs during exercise that subsides with rest, is a hallmark symptom of PAD. It occurs due to reduced blood flow to the muscles during activity.
Choice D rationale
Edema is more commonly associated with venous insufficiency or heart failure rather than PAD. PAD typically causes reduced blood flow, not fluid accumulation.
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View Related questions
Correct Answer is A
Explanation
Choice A rationale
Determining the patency of the tubing is the first action the nurse should take. If there is no urinary output, it is important to check for any kinks or blockages in the tubing that may be preventing the flow of urine. Ensuring the patency of the tubing can help resolve the issue without the need for further intervention.
Choice B rationale
Notifying the provider is not the first action the nurse should take. The nurse should first assess the situation and determine if there is a simple solution, such as checking the patency of the tubing, before escalating the issue to the provider.
Choice C rationale
Administering a prescribed analgesic is not the first action the nurse should take. While pain management is important, it is crucial to address the lack of urinary output first to prevent complications such as bladder distention or damage.
Choice D rationale
Offering oral fluids is not the first action the nurse should take. While maintaining hydration is important, the immediate concern is to determine why there is no urinary output and address any potential blockages in the tubing.
Correct Answer is ["B","C","E"]
Explanation
Choice A rationale
Acetone breath is a characteristic symptom of diabetic ketoacidosis (DKA), not hyperosmolar hyperglycemic syndrome (HHS). In DKA, the body produces ketones, leading to a fruity or acetone-like breath odor. HHS, on the other hand, does not typically involve significant ketone production.
Choice B rationale
Fever can be a manifestation of HHS, often due to an underlying infection or illness that precipitates the hyperglycemic state. Infections are common triggers for HHS, leading to elevated body temperature.
Choice C rationale
Serum glucose levels of 800 mg/dL are indicative of HHS. HHS is characterized by extremely high blood glucose levels, often exceeding 600 mg/dL, without significant ketoacidosis.
Choice D rationale
Serum bicarbonate levels of 15 mEq/L are more indicative of DKA rather than HHS. In HHS, bicarbonate levels are usually within the normal range because there is no significant ketoacidosis.
Choice E rationale
Insidious onset is a hallmark of HHS. The condition develops gradually over days to weeks, unlike DKA, which has a more rapid onset.