The nurse admits the client with a left medial ulcer just above the ankle. Which assessment finding of the lower extremities is the most consistent with the primary cause of the client's ulc-er?
1. Brownish color to skin
2. Taut, shiny skin at ankles
3. Impaired perfusion to feet
4. Skin warm down to ankles
1
1. Medial ulcers of the lower extremities are consistent with chronic venous insuffi-ciency; the affected extremity usually has brownish skin.
2. Venous insufficiency impairs venous blood return to the heart, so fluid accumulates in dependent positions; the skin is usually dull, flaky or scaly, and edematous.
3. Faint peripheral pulses are characteristic of venous insufficiency because of diffi-culty with palpation through edematous tissue and are not usually the result of im-paired arterial blood flow.
4. Because arterial blood flow is usually adequate with venous insufficiency, skin is normally warm.
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