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 C
Explanation
A. "A heart murmur is a high-pitched sound due to a narrow valve." Not all murmurs are high-pitched, nor are they always due to a narrow valve.
B. "This means that there is some inflammation around your heart." A murmur does not indicate inflammation around the heart; it typically indicates abnormal blood flow.
C. "This indicates turbulent blood flow through a valve." A heart murmur is caused by turbulent blood flow, often through a damaged or abnormal valve.
D. "A heart murmur is an extra sound due to blood entering an inflexible chamber." While inflexible chambers can cause extra heart sounds, this does not describe a murmur.
Correct Answer is B
Explanation
A. Swelling of the lower extremity can create a wound that is difficult to heal. Swelling typically relates to venous ulcers, not arterial ulcers, which are caused by reduced blood flow.
B. Decreased blood flow to the area can cause the wound and decrease the healing. Peripheral artery disease causes decreased blood flow, leading to poor oxygenation and slow healing of arterial ulcers.
C. Lower extremity compression stockings likely caused the wound to occur. Compression stockings are used in venous insufficiency and do not cause arterial ulcers.
D. Increased blood sugar associated with the condition is likely the cause of the wound not healing. While high blood sugar can impair healing, decreased blood flow is the primary cause of arterial ulcers in PAD.