The nurse is performing a head-to-toe assessment on a resident in a long-term care facility with a history of angina pectoris. When assessing peripheral perfusion, the nurse will perform which intervention(s)? (Select all that apply.)
a. Count heart rate and describe rhythm.
b. Note any loss of hair on lower legs.
c. Auscultate blood pressure.
d. Check pedal pulses.
e. Assess pupil reaction.
ANS: B, D
Peripheral perfusion assessment includes noting loss of hair on lower legs, denoting decreased circulation. When assessing peripheral perfusion, the pedal pulses in the lower extremities are assessed in conjunction with skin color and temperature. Heart rate and rhythm are components of assessment of the cardiovascular system but not associated with peripheral tissue perfusion. Pupil reaction is considered a neurologic assessment.
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