The nursing diagnosis for the client with arterial insufficiency is "impaired peripheral perfusion.". Which assessment data about the client's lower extremities supports the nurse's conclusion?
1. Ankles with shallow ulcers
2. Bilateral skin warm and pink
3. Aching in a dependent position
4. Bilateral absent peripheral pulses
4
4. Clinical indicators of impaired perfusion to a lower extremity include absent or diminished pulses, cool and dusky skin, and pain on exertion; if the disease is ad-vanced, the client potentially has pain at rest.
1 and 3. Lower extremities with shallow ankle ulcers and aching in the dependent position are characteristic of venous insufficiency.
2. Warm pink skin is a clinical indicator of adequate tissue oxygenation.
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