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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?

A.

Bronze pigmentation.

B.

Uneven hair distribution.

C.

Lower leg edema.

D.

Bounding peripheral pulse.

Answer and Explanation

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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View Related questions

Correct Answer is C

Explanation

A. Immediately after the patient has been medicated for pain.
While pain relief may help, education should be conducted when the patient is alert and comfortable, not immediately after pain medication when they may be drowsy.

B. The last thing in the evening, after visitors have left, before bedtime. Education right before bedtime may not be effective if the patient is tired, as retention and attention may be reduced.

C. When the patient is comfortable and receptive to the patient education.
Teaching should occur when the patient is comfortable, alert, and receptive to ensure they can retain and understand the information.

D. Just before the patient is discharged, so the information is current.
Waiting until discharge could overwhelm the patient, and they may not have time to ask questions or clarify information.

Correct Answer is A

Explanation

A. The elevated heart rate and respirations suggest the client may be experiencing hypoxia, especially following a thoracotomy. Administering oxygen will help improve oxygen saturation levels and address potential respiratory distress.

B. While pain management is essential, the immediate concern is ensuring adequate oxygenation.

C. Administering IV fluids may be necessary but is secondary to ensuring the client's oxygenation.

D. Encouraging the client to splint and cough is important for preventing complications but does not address the immediate issue of vital signs indicating possible respiratory compromise.

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