NCLEX-style case study · Free sample
NCLEX-RN Adult Health Case Study 3
Client record
Item 1 of 6
The nurse is caring for a 64-year-old client.
Day 1 — Initial Vascular Assessment, 0800
Initial Nursing Assessment — Day 1
- 0800:
The client reports a two-week history of sharp bilateral lower-extremity pain that worsens with walking and is associated with numbness and tingling. Over the past two days, the pain has worsened and has prevented the client from sleeping at night.
Day 1 — Initial Vascular Assessment, 0800
Medical History and Vascular Examination
Relevant Medical History
Type 2 diabetes mellitus for 10 years. Hypertension for 4 years. Cigarette smoking for 15 years; stopped 1 month ago. Reports alcohol use over the past 12 years.
Physical Examination
General condition fair. Client appears in mild pain, is afebrile, and has no pallor. Cardiovascular: Upper extremities warm. S1 and S2 audible; no murmurs. Left lower extremity: Loss of hair, shiny skin, and coolness to touch. A small, clean ulcer measuring 2 cm × 1 cm is present on the fifth toe. Right lower extremity: Loss of hair and coolness to touch. No ulceration observed.
Day 1 — Initial Vascular Assessment, 0800
Vital Signs — Day 1, 0800
| Item | Day 1 — 0800 |
|---|---|
| Blood pressure | 156/92 mmHg |
| Heart rate | 96/min |
| Temperature | 37.5°C (99.5°F) |
| Oxygen saturation | 98% on room air |
Item 1 of 6
Click to highlight the findings that suggest impaired arterial perfusion of the lower extremities and require further vascular assessment.
Select all applicable findings in the passage.
Choose a dotted phrase to highlight it, and choose it again to remove the highlight.
At 0800 hours, a 64-year-old client reports . The client also reports , accompanied by . Examination of the left leg reveals . A is present. The right leg also demonstrates . The cardiovascular examination reveals . The client's upper extremities are . Vital signs include and . Blood pressure is 156/92 mmHg and heart rate is 96/min.
0 findings selected.