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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Correct Answer is D
Explanation
Choice A rationale
Positioning the lower extremities so that they are touching is incorrect because it can lead to adduction of the hip, which increases the risk of dislocation. After a total hip arthroplasty, it is important to maintain proper alignment of the hip joint to prevent dislocation. Keeping the legs apart with the use of an abduction pillow or wedge is recommended to maintain proper alignment and reduce the risk of complications.
Choice B rationale
Ensuring that the client’s heels are touching the bed is incorrect because it can lead to pressure ulcers. After a total hip arthroplasty, it is important to prevent pressure on the heels by using pillows or heel protectors to elevate the heels off the bed. This helps to reduce the risk of pressure ulcers and promotes better circulation to the lower extremities.
Choice C rationale
Instructing the client to avoid movement of the affected leg is incorrect because early mobilization is important for recovery. After a total hip arthroplasty, patients are encouraged to perform gentle exercises and mobilize as soon as possible to prevent complications such as deep vein thrombosis (DVT) and to promote healing. Immobilization can lead to stiffness, muscle atrophy, and other complications.
Choice D rationale
Preventing hip flexion of the affected extremity is correct because excessive hip flexion can increase the risk of dislocation. After a total hip arthroplasty, it is important to avoid positions that involve hip flexion greater than 90 degrees, such as sitting in low chairs or bending forward excessively. Maintaining proper hip precautions helps to reduce the risk of dislocation and promotes a safe recovery.
Correct Answer is D
Explanation
Choice A rationale
Constipation is not a common adverse effect of aspirin therapy. Aspirin primarily affects the gastrointestinal tract by causing irritation, which can lead to symptoms such as nausea, vomiting, and abdominal pain. Constipation is more commonly associated with medications that slow down bowel movements, such as opioids.
Choice B rationale
Blurred vision is not typically associated with aspirin therapy. Aspirin is a nonsteroidal anti- inflammatory drug (NSAID) that works by inhibiting the production of prostaglandins, which are involved in inflammation and pain. Blurred vision is more commonly associated with medications that affect the central nervous system or have anticholinergic effects.
Choice C rationale
Insomnia is not a common adverse effect of aspirin therapy. Aspirin does not have stimulant properties that would interfere with sleep. Insomnia is more commonly associated with medications that have stimulating effects, such as caffeine or certain antidepressants.
Choice D rationale
Bleeding is a well-known adverse effect of aspirin therapy. Aspirin inhibits platelet aggregation, which can increase the risk of bleeding. This can manifest as gastrointestinal bleeding, easy bruising, or prolonged bleeding from cuts. Patients taking aspirin should be monitored for signs of bleeding and advised to report any unusual bleeding to their healthcare provider.