Question

A nurse is admitting a client who has a leg ulcer and a history of diabetes mellitus. The nurse should use which of the following focused assessments 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

The nurse should measure the ankle-brachial index (ABI) to differentiate between an arterial ulcer and a venous stasis ulcer, with each type of ulcer showing distinct characteristics relevant to the underlying circulation issues.

Step-by-step explanation:

To differentiate between an arterial ulcer and a venous stasis ulcer, the nurse should measure the ankle-brachial index (ABI). This diagnostic tool compares the blood pressure measured at the ankle with the blood pressure measured at the arm to assess for peripheral artery disease (PAD), which is often associated with arterial ulcers.

They are often the result of atherosclerosis and reduced blood flow. On the other hand, venous stasis ulcers tend to occur on the lower legs and are often associated with edema, skin changes such as stasis dermatitis, and a history of varicose veins or deep vein thrombosis (DVT). Checking for the presence of edema and observing for the presence of granulation tissue can additionally aid the assessment of the ulcer etiology, completing a comprehensive examination alongside ABI measurement.