The nurse is performing the assessment of an elderly client recently diagnosed with arterial insufficiency due to atherosclerosis. Which of the following findings are consistent with this condition? Standard Text: Select all that apply
1. Bilateral pitting edema 3+ in ankles and feet
2. Carotid bruit present
3. Blood pressure 180/94
4. Peripheral pulses 1+/4+ in dorsalis pedis bilaterally
5. A pea-sized ulcer noted on the client's right great toe, no drainage, well-defined edges
2,3,4,5
Rationale 1: Bilateral pitting edema 3+ in ankles and feet. Bilateral pitting edema is most often attributed to right-sided heart failure.
Rationale 2: arotid bruit present. A narrowing of the carotid artery, as occurs with atherosclerosis, will result in turbulent blood flow. This causes the swishing sound known as a bruit.
Rationale 3: Blood pressure 180/94. Clients with atherosclerosis and arterial insufficiency may have hypertension.
Rationale 4: Peripheral pulses 1+/4+ in dorsalis pedis bilaterally. Atherosclerosis and arterial insufficiency may result in decreased peripheral pulses.
Rationale 5: A pea-sized ulcer noted on the client's right great toe, no drainage, well-defined edges. The client with arterial insufficiency may develop ulcers such as this one.
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