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 C
Explanation
Choice A rationale
Freezing unopened insulin vials is incorrect. Insulin should be stored in the refrigerator at a temperature between 36°F and 46°F (2°C and 8°C) until it is opened. Freezing insulin can cause it to lose its potency and effectiveness. Once opened, insulin vials can be kept at room temperature for up to 28 days, but they should never be frozen.
Choice B rationale
Increasing insulin when exercising is incorrect. Exercise generally lowers blood glucose levels, so clients with type 1 diabetes may need to decrease their insulin dose or consume additional carbohydrates to prevent hypoglycemia during and after physical activity. It is important for clients to monitor their blood glucose levels closely and adjust their insulin and carbohydrate intake accordingly.
Choice C rationale
Injecting insulin into the abdominal area is correct. The abdominal area is one of the recommended sites for insulin injection because it has a large surface area and provides consistent absorption. Other recommended sites include the upper outer arms, thighs, and buttocks. Rotating injection sites within the same area helps prevent lipodystrophy and ensures better insulin absorption.
Choice D rationale
Shaking the insulin vial vigorously to mix is incorrect. Insulin vials should be gently rolled between the hands to mix the contents. Shaking the vial vigorously can cause air bubbles to form, which can lead to inaccurate dosing. Proper mixing ensures that the insulin is evenly distributed and effective.
Correct Answer is ["A","D"]
Explanation
Choice A rationale
Monitoring the puncture site for hematoma is crucial because a hematoma can indicate bleeding at the puncture site, which can lead to complications such as infection or nerve damage. Hematomas can also cause increased intracranial pressure, which can be dangerous for the patient. Therefore, it is essential to monitor the site closely to ensure that any signs of bleeding are detected early and managed appropriately.
Choice B rationale
Elevating the client’s head of bed is incorrect because it can increase the risk of cerebrospinal fluid (CSF) leakage from the puncture site. After a lumbar puncture, it is recommended to keep the patient in a flat position for several hours to reduce the risk of post-lumbar puncture headache and to allow the puncture site to heal properly. Elevating the head of the bed too soon can disrupt this process and lead to complications.
Choice C rationale
Inserting a urinary catheter is incorrect because it is not a standard procedure following a lumbar puncture. The primary focus after a lumbar puncture is to monitor for complications related to the procedure itself, such as bleeding, infection, or CSF leakage. Inserting a urinary catheter is not necessary unless there is a specific indication for it, such as urinary retention or other urological issues.
Choice D rationale
Encouraging fluid intake is correct because it helps to replenish the CSF that was removed during the lumbar puncture. Increased fluid intake can also help to reduce the risk of post- lumbar puncture headache, which is a common complication. Hydration is important for overall recovery and helps to maintain normal bodily functions.
Choice E rationale
Applying a cervical collar to the client is incorrect because it is not related to the care of a lumbar puncture site. A cervical collar is typically used for patients with neck injuries or conditions affecting the cervical spine. It has no role in the management of a lumbar puncture site and would not provide any benefit in this context.