Question

A nurse is admitting a client who has a leg ulcer and a history of diabetes mellitus. Which of the following focuses assessments should the nurse use to help differentiate between an arterial ulcer and a venous stasis ulcer?

A. Assess for hair loss on the lower extremities
B. Measure ankle-brachial index (ABI)
C. Check for the presence of edema
D. Observe for the presence of granulation tissue

Answer 1

To differentiate between an arterial ulcer and a venous stasis ulcer, the nurse should focus on assessing the ankle-brachial index (ABI), the presence of edema, and observing for granulation tissue.

Step-by-step explanation:

To differentiate between an arterial ulcer and a venous stasis ulcer, the nurse should focus on the following assessments:

1. Ankle-brachial index (ABI): This is a measurement that compares the blood pressure in the ankle to the blood pressure in the arm. A lower ABI is indicative of arterial disease and can help differentiate an arterial ulcer from a venous stasis ulcer.
2. Presence of edema: Edema is often associated with venous stasis ulcers caused by impaired venous return. Assessing for edema can help identify a venous stasis ulcer.
3. Observing for granulation tissue: Granulation tissue is a sign of healing and is typically present in arterial ulcers but may be absent in venous stasis ulcers.

By utilizing these assessments, the nurse can gather important information to help differentiate between an arterial ulcer and a venous stasis ulcer in a client with a leg ulcer and a history of diabetes mellitus.