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MS2 EAQ
[Document subtitle]
, MS2 EAQ
1. Which 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: 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.
2. 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.
, MS2 EAQ
Crackles
Coughing
Orthopnea
Yellow sputum
Anxiety
Dependent edema
Restlessness
Lethargy: 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.
3. When a client develops internal bleeding after abdominal surgery, which clinical
manifestation would the nurse expect the client to exhibit? Select all that apply. One,
some, or all responses may be correct.
Pallor
MS2 EAQ
[Document subtitle]
, MS2 EAQ
1. Which 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: 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.
2. 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.
, MS2 EAQ
Crackles
Coughing
Orthopnea
Yellow sputum
Anxiety
Dependent edema
Restlessness
Lethargy: 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.
3. When a client develops internal bleeding after abdominal surgery, which clinical
manifestation would the nurse expect the client to exhibit? Select all that apply. One,
some, or all responses may be correct.
Pallor
