Following admission, a client with a vascular occlusion of the right lower extremity calls the nurse and reports difficulty sleeping because of cold feet. Which of the following nursing actions should the nurse take to promote the client's comfort?
Obtain a pair of slipper socks for the client.
Increase the client's oral fluid intake.
Rub the client's feet briskly for several minutes.
Place a moist heating pad under the client's feet.
The Correct Answer is A
A. Obtain a pair of slipper socks for the client. Slipper socks can provide warmth without applying direct heat, which is safer for clients with impaired circulation.
B. Increase the client's oral fluid intake. Increasing fluids does not directly address cold feet and may be contraindicated depending on the client’s condition.
C. Rub the client's feet briskly for several minutes. Rubbing can damage skin and tissue in clients with poor circulation and should be avoided.
D. Place a moist heating pad under the client's feet. Heating pads can cause burns and further impair circulation in clients with vascular issues.
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Correct Answer is B
Explanation
A. Warm extremities. PAD typically leads to cold extremities due to poor blood flow.
B. Intermittent claudication. Intermittent claudication, or muscle pain during exercise, is a classic symptom of PAD caused by limited blood supply to the muscles.
C. Darkened skin color near extremities. Darkened skin is more common in venous insufficiency, not PAD. PAD can cause pale or bluish skin.
D. Edema. Edema is typically associated with venous insufficiency, not PAD.
Correct Answer is B
Explanation
A. "I am constipated." Constipation is not a common indicator of digoxin toxicity; it may be more related to diet or other medications.
B. "My vision seems yellow." Yellow or blurred vision, also called xanthopsia, is a classic sign of digoxin toxicity and should be reported immediately.
C. "My tongue is red and beefy." A red and beefy tongue may indicate vitamin B12 deficiency, not digoxin toxicity.
D. "I am gaining weight." Weight gain is usually a sign of fluid retention or worsening heart failure, not specifically digoxin toxicity.