Question

The nurse notes that a client's legs become dusky-red whenever the client is sitting with both feet dangling. Which follow-up assessment should the nurse complete?

a. Ankle brachial index (ABI).

b. Joint range of motion.

c. Calf diameter.

d. Skin elasticity.

Answer 1

The nurse should complete an Ankle Brachial Index (ABI) as it is the most appropriate follow-up assessment for a client with dusky-red legs when sitting with feet dangling, indicating possible vascular compromise.

Step-by-step explanation:

The nurse observes a client whose legs become dusky-red when sitting with feet dangling. This could indicate vascular compromise or peripheral blood flow issues. The most appropriate follow-up assessment to complete in this scenario is an Ankle Brachial Index (ABI). An ABI assesses the ratio of the blood pressure in the lower legs to the blood pressure in the arms, which helps in diagnosing peripheral artery disease (PAD). Measurements such as joint range of motion, calf diameter, and skin elasticity may provide additional information but would not directly assess blood flow issues as effectively as ABI.

Regarding the patient's skeletal muscle pump, this mechanism aids in the return of blood to the heart, especially in the lower extremities. As the patient is obese and engages in no physical activity, the skeletal muscle pump is likely compromised, leading to venous insufficiency, which could explain her symptoms of swollen feet and ankles, fatigue, and shortness of breath. This is especially relevant because her long periods of standing at work without sufficient muscle movement can result in inadequate blood flow return from the lower extremities.