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NUR 4271 Med Surg 1 EAQ Exam
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NUR 4271 Med Surg 1 EAQ ExamWhich finding would the nurse expect when assessing a client with peripheral arterial
disease (PAD)? Select all that apply. One, some, or all responses may be correct.
Pallor of feet
Warm extremities
Ulcers on the toes
Delayed capillary refill
Thick, hardened skin
Hair loss to lower extremities
Muscle atrophy
Intermittent claudication - ANSWER Pallor of feet, Ulcers on the toes, Delayed capillary
refill, Hair loss to lower extremities, Muscle atrophy, Intermittent claudication.
PAD affects arterial circulation and results in delayed and impaired circulation to the
extremities. As a result, the extremities exhibit pallor, ulcers on the feet and toes, cool
skin, and capillary refill longer than 3 seconds. Hair loss to the lower calf, ankle and foot
are noted with PAD. Chronic PAD can result in muscle atrophy. Intermittent claudication
is the most common presenting symptom of this disease. Warm extremities occur with
venous disease. Venous disease leads to thick, hardened skin on the legs.
The nurse reviews the electronic health record and documents visit-related care in the
nursing progress notes. Labs drawn and imaging completed per provider orders.
Which clinical manifestations will the nurse expect when caring for a client with a
diagnosis of pulmonary edema? Select all that apply. One, some, or all responses may
be correct. - ANSWER Crackles, Coughing, Orthopnea, Anxiety, Restlessness, Lethargy
In pulmonary edema, fluid moves into the pulmonary interstitial space and then into the
alveoli; this results in crackles, severe dyspnea, and coughing. Sitting upright while
leaning forward with the arms supported (orthopnea) is an attempt to maximize thoracic
expansion and limit the pressure of abdominal organs against the diaphragm. The client
, with pulmonary edema may present as anxious, restless, or with generalized lethargy.
Yellow sputum indicates infection, not pulmonary edema. With pulmonary edema the
sputum may be frothy and blood tinged. Pulmonary interstitial edema, not dependent
edema, occurs.
The nurse reviews the electronic health record system for client information and
documents care in the nursing progress notes. Client care implemented per provider
orders.
When a client develops internal bleeding after abdominal surgery, which clinical
manifestation would the nurse expect the client to exhibit? - ANSWER Pallor, Decreased
mean arterial pressure (MAP), Tachycardia
Pallor occurs as the peripheral blood vessels constrict in an effort to shunt blood to the
vital organs in the center of the body. During the initial stages, MAP will decrease 5-10
mm Hg due to the blood pressure dropping. Heart rate accelerates (tachycardia) in
hemorrhage as the body attempts to increase blood flow and oxygen to body tissues.
Urinary output decreases (the opposite of polyuria) with hemorrhage because of a
lowered glomerular filtration rate secondary to hypovolemia. Respirations increase (the
opposite of bradypnea) and become shallow with hemorrhage as the body attempts to
take in more oxygen. Hypotension, not hypertension, occurs in response to hemorrhage
as the person experiences hypovolemia. With loss of blood the pulse pressure will
decrease and skin will become cold, not warm, to the touch and moist due to reduced
blood flow.
The nurse reviews the electronic health record for pre-appointment labs and imaging
and documents visit-related care in the nursing progress notes.
When assessing a client with varicose veins, which clinical manifestation would the
nurse expect to find? - ANSWER Presence of ankle edema, Increased leg fatigue, Report
of leg fullness and pruritis.
Presence of ankle edema, increased leg fatigue, and a report of leg fullness and pruritus
are signs of varicose veins, due to poor venous return and increased venous pressure.
Diminished peripheral pulses occur with decreased arterial blood flow. Intermittent
claudication (as evidenced by leg pain with activity that resolves with rest) occurs with
decreased arterial, not venous, perfusion. Additional signs of peripheral artery disease
(PAD) include hair loss on lower calf, ankle, and foot areas along with thickened
toenails. The nurse would expect to see brown pigmentation or skin staining, not pallor,
associated with extravasated red blood cells in lower extremities.
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