On assessing a client's lower extremities, the nurse notices that one leg is pale and cooler to the touch. Which assessment does the nurse perform next?
a. Ask about a family history of skin disord-ers.
b. Palpate the client's pedal pulses bilaterally.
c. Check for the presence of Homans' sign.
d. Assess the client's skin for adequate skin turgor.
B
Localized, decreased skin temperature and pallor indicate interference with vascular flow to the region. The nurse should assess bilateral pedal pulses to screen for vascular sufficiency. Without adequate blood flow, the client's limb could be threatened. Asking about a family history of skin problems would not take priority over assessing blood flow. Homans' sign is a screening tool for deep vein thrombosis and is often inaccurate. Skin turgor gives information about hydration sta-tus. This assessment may be needed but certainly does not take priority over assessing for blood flow.
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