Amputation due to Peripheral Vascular Disease

2. Loss of hair on the lower leg. Rationale: The client with severe arterial occlusive disease and gangrene of the left great toe would have lost the hair on the leg due to decreased circulation to the skin.

A client has severe arterial occlusive disease and gangrene of the left great toe. Which of the following findings is expected? 1. Edema around the ankle. 2. Loss of hair on the lower leg. 3. Thin, soft toenails. 4. Warmth in the foot.

4. Give the client the prescribed opioid analgesic. Rationale: The nurse's first action should be to administer the prescribed opioid analgesic to the client, because this phenomenon is phantom sensation and interventions should be provided to relieve it. Pain relief is the priority. Phantom sensation is a real sensation.

A client in the post-anesthesia care unit with a left below-the-knee amputation has pain in her left big toe. Which of the following should the nurse do first? 1. Tell the client it is impossible to feel the pain. 2. Show the client that the toes are not there. 3. Explain to the client that her pain is real. 4. Give the client the prescribed opioid analgesic.

2. "Tell me more about how you're feeling." Rationale: Encouraging the client who will be undergoing amputation to verbalize his feelings is the most therapeutic response. Asking the client to tell more about how he is feeling helps to elicit information, providing insight into his view of the situation and also providing the nurse with ideas to help him cope.

A client says, "I hate the idea of being an invalid after they cut off my leg." Which of the following would be the nurse's most therapeutic response? 1. "At least you will still have one good leg to use." 2. "Tell me more about how you're feeling." 3. "Let's finish the preoperative teaching." 4. "You're lucky to have a wife to care for you."

4. Draw a mark around the site. Rationale: The priority action is to draw a mark around the site of bleeding to determine the rate of bleeding. Once the area is marked, the nurse can determine whether the bleeding is increasing or decreasing by the size of the area marked. Because the spot is bright red, the bleeding is most likely arterial in origin.

A client who has had an above-the-knee amputation develops a dime-sized bright red spot on the dressing after 45 minutes in the post-anesthesia recovery unit. The nurse should: 1. Elevate the stump. 2. Reinforce the dressing. 3. Call the surgeon. 4. Draw a mark around the site.

3. Keep the client tobacco-free for 30 minutes before the test. Rationale: The client should be tobacco-free for 30 minutes before the test to avoid false readings related to the vasoconstrictive effects of smoking on the arteries.

A client with absent peripheral pulses and pain at rest is scheduled for an arterial Doppler study of the affected extremity. When preparing the client for this test, the nurse should: 1. Have the client sign a consent form for the procedure. 2. Administer a pretest sedative as appropriate. 3. Keep the client tobacco-free for 30 minutes before the test. 4. Wrap the client's affected foot with a blanket.

2. The adequacy of the blood supply to the tissues. Rationale: The level of amputation often cannot be accurately determined until during surgery, when the surgeon can directly assess the adequacy of the circulation of the residual limb. From a moral, ethical, and legal viewpoint, the surgeon attempts to remove as little of the leg as possible.

The client asks the nurse, "Why can't the physician tell me exactly how much of my leg he's going to take off? Don't you think I should know that?" On which of the following should the nurse base the response? 1. The need to remove as much of the leg as possible. 2. The adequacy of the blood supply to the tissues. 3. The ease with which a prosthesis can be fitted. 4. The client's ability to walk with a prosthesis.

4. Assessing the client's and family's typical food preferences. Rationale: Before beginning dietary instructions and interventions, the nurse must fi rst assess the client's and family's food preferences, such as pattern of food intake, life style, food preferences, and ethnic, cultural, and financial influences. Once this information is obtained, the nurse can begin teaching based on the client's current knowledge level and then building on this knowledge base.

The client is to be discharged on a low-fat, low-cholesterol, low-sodium diet. Which of the following should be the nurse's first step in planning the dietary instructions? 1. Determining the client's knowledge level about cholesterol. 2. Asking the client to name foods that are high in fat, cholesterol, and salt. 3. Explaining the importance of complying with the diet. 4. Assessing the client's and family's typical food preferences.

4. Triceps stretching exercises. Rationale: Use of crutches requires signifi cant strength from the triceps muscles. Therefore, efforts are focused on strengthening these muscles in anticipation of crutch walking. Bed and wheelchair push-ups are excellent exercises targeted at the triceps muscles.

The client with an above-the-knee amputation is to use crutches while his prosthesis is being adjusted. In which of the following exercises should the nurse instruct the client to best prepare him for using crutches? 1. Abdominal exercises. 2. Isometric shoulder exercises. 3. Quadriceps setting exercises. 4. Triceps stretching exercises.

4. Triceps stretching exercises. Rationale: When using crutches, the client is taught to support her weight primarily on the hands. Supporting body weight on the axillae, elbows, or upper arms must be avoided to prevent nerve damage from excessive pressure.

The client with an above-the-knee amputation is to use crutches while his prosthesis is being adjusted. In which of the following exercises should the nurse instruct the client to best prepare him for using crutches? 1. Abdominal exercises. 2. Isometric shoulder exercises. 3. Quadriceps setting exercises. 4. Triceps stretching exercises.

2. Walking slowly but steadily for 30 minutes twice a day. Rationale: Slow, steady walking is a recommended activity for the client with peripheral arterial disease because it stimulates the development of collateral circulation needed to ensure adequate tissue oxygenation.

The client with peripheral arterial disease says, "I've really tried to manage my condition well." Which of the following should the nurse determine as appropriate for this client? 1. Resting with the legs elevated above the level of the heart. 2. Walking slowly but steadily for 30 minutes twice a day. 3. Minimizing activity as much and as often as possible. 4. Wearing antiembolism stockings at all times when out of bed.

3. Current age of 39 years. Rationale: Typically, peripheral vascular disease is considered to be a disorder affecting older adults. Therefore, an age of 39 years would not be considered as a risk factor contributing to the development of peripheral vascular disease.

Which of the following should the nurse identify as the least likely factor contributing to a client's peripheral vascular disease? 1. Uncontrolled diabetes mellitus for 15 years. 2. A 20-pack-year history of cigarette smoking. 3. Current age of 39 years. 4. A serum cholesterol concentration of 275 mg/dL.

1. Daily lubrication of the feet. Rationale: Daily lubrication, inspection, cleaning, and patting dry of the feet should be performed to prevent cracking of the skin and possible infection.

Which of the following should the nurse include in the teaching plan for a client with arterial insufficiency to the feet that is being managed conservatively? 1. Daily lubrication of the feet. 2. Soaking the feet in warm water. 3. Applying antiembolism stockings. 4. Wearing firm, supportive leather shoes.