The nurse is performing a physical assessment of a client. Which finding should the nurse recognize is a result of compromised peripheral arterial circulation of the lower extremity?
Bronze pigmentation.
Uneven hair distribution.
Lower leg edema.
Bounding peripheral pulse.
The Correct Answer is B
A. Bronze pigmentation is often associated with venous insufficiency rather than arterial compromise.
B. Compromised peripheral arterial circulation can lead to decreased blood flow, resulting in uneven or diminished hair distribution on the lower extremities due to lack of nourishment to hair follicles.
C. Lower leg edema is more commonly associated with venous insufficiency rather than arterial insufficiency.
D. A bounding peripheral pulse indicates increased arterial pressure or volume, which is not consistent with compromised arterial circulation, where pulses are typically weak or absent.
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Correct Answer is D
Explanation
A. Encouraging physical activity, such as walking, is important for cardiovascular health, but it is not a measurable outcome related to the client's current condition of blurred vision and cardiovascular disease.
B. While educating the family about signs and symptoms is valuable, it does not directly address the client's health status or outcomes that can be measured.
C. A target blood pressure of less than 160/90 mm Hg does not adequately control hypertension and may still pose a risk to cardiovascular health, especially given the blurred vision, which could indicate possible complications.
D. Setting a goal for the client’s daily blood pressure to be less than 140/80 mm Hg is a clear, measurable outcome that indicates effective management of hypertension and promotes overall cardiovascular health. This target is aligned with current clinical guidelines for hypertension management.
Correct Answer is C
Explanation
A. While frequent mouth care is important, it is not the most immediate concern during an active seizure. The priority is to maintain airway patency and prevent aspiration.
B. Maintaining a semi-Fowler's position may be beneficial, but the client’s level of consciousness and the presence of seizures require more immediate interventions focused on airway management.
C. Ensuring oral suction is available is essential for the client who is unconscious and experiencing seizures, as it allows for rapid intervention to clear secretions and prevent aspiration, which is critical for airway protection.
D. Keeping the room at a comfortable temperature is important for the overall comfort of the client, but it does not directly address the acute management of seizures and airway concerns.