An older adult sleeps in a recliner with cool, grayish-colored feet on the floor. Which should the nurse investigate to assess the vascular status of this older adult?
a. Ability to stand during activities of daily living
b. Lateral ulcerations with brownish discoloration
c. Complaints of dull aching and peripheral edema
d. History of hypercholesterolemia and hypertension
D
Feedback
A Incorrect. To assess an older adult with signs of arterial insufficiency, the nurse examines the distance the adult can walk without pain. The older adult with pe-ripheral arterial disease can stand without pain because dependent positioning of the feet helps to perfuse hypoxic tissues.
B Incorrect. Lateral ulcerations are clinical indicators of venous insufficiency.
C Incorrect. Dull aching and peripheral edema are clinical indicators of venous insufficiency.
D Correct. The nurse examines the older adult's history of a dyslipidemia and hypertension to help determine the vascular status because histories of these disorders are risk factors for peripheral arterial disease.
You might also like to view...
Economic factors that are highly critical to the success of discharge planning for a client with severe
and persistent mental illness include (more than one answer may be correct) A. access to housing. B. income adequate to meet basic needs. C. availability of health insurance. D. ongoing interdisciplinary evaluation.
A group of nurses is visiting a community where they want to address the rate of tobacco use in pregnant women, but they only have a short amount of time to prepare for their trip. What is their first step?
A. Create a fish bone diagram. B. Assess the community for social and demographic data. C. Create objective, easy to assess goals. D. Identify populations more likely to smoke.
Johnny is a 5-year-old child who is on your medical floor for treatment of an exacerbation of his leukemia. His family lives a long distance away. You see him sitting alone and he says he is "too tired and sad to play with the other children
" Your therapeutic intervention for Johnny would be: A) "Johnny, I have some time now and I'd like to play with you. What shall we do?" B) "Johnny, you know it won't do you any good to feel sad." C) "Johnny, playing with the other children might help you to forget that your family is not here." D) "Johnny, you should be in bed if you are so tired."
Upon entering the examination room, a nurse observes that the client is leaning forward with arms supporting body weight. The nurse would most likely suspect which of the following?
A) Diabetes mellitus B) Heart failure C) Chronic obstructive pulmonary disease D) System lupus erythematosus