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 A
Explanation
A. Administering opioid and non-opioid medications together is an effective pain management strategy for severe pain. This approach can provide better pain relief by targeting different pain pathways and may reduce the total dosage of opioids needed, thus minimizing side effects.
B. Alternating IV and IM analgesic medications is not the best approach; instead, consistent pain management is necessary to keep pain levels under control.
C. Waiting until the pain score reaches 10 before administering the maximum dosage is inappropriate and could lead to inadequate pain control. Pain management should be proactive, not reactive.
D. While educating the client on narcotic dependency is important, it is not the priority intervention in this acute situation where pain control is essential. The immediate focus should be on effective pain relief.
Correct Answer is A
Explanation
A. Monitoring for occult blood in urine and stool is crucial in clients with low platelet counts to detect any potential bleeding early, as they are at increased risk of bleeding due to thrombocytopenia.
B. Using a large gauge catheter may be necessary for some procedures, but it is not the priority intervention regarding the client’s current state and platelet count.
C. Removing cold and frozen foods from dietary trays does not directly address the critical concern of bleeding associated with low platelet levels.
D. While protecting bruised areas is important, it is secondary to monitoring for active bleeding, which is more critical at this stage.