The nurse is performing a medical and physical assessment on a new client. The client is overweight and admits to a sedentary lifestyle. The nurse palpates pulses on the lower leg, the legs are warm to touch, and a normal capillary refill is present. In addition, there is an open wound medially on the ankle of one leg. Which condition does the nurse identify?

Question

Quizplus · Accepted Answer

The presence of an open wound on the ankle, combined with the client's overweight status and sedentary lifestyle, suggests venous insufficiency. Venous insufficiency can lead to ulcers, particularly around the ankles, due to poor blood flow back to the heart. The fact that the legs are warm to the touch and have a normal capillary refill indicates that arterial blood flow is not the issue, which helps differentiate it from arterial obstruction.

The Nurse Is Performing a Medical and Physical Assessment on a New