Which conclusion would the nurse be concerned about after squeezing the patient's toe and observing that blanching persists for more than 3 seconds after releasing the pressure? A) Congestion B) Hyperthermia C) Hypertension D) Impaired circulation
Answer (1)
The nurse's observation of the patient's toe where blanching persists for more than 3 seconds after releasing the pressure is a clinical test called 'capillary refill time.'
Capillary refill time is used to assess peripheral perfusion and hydration status. Normally, when you apply pressure to a toenail or fingernail, the skin should blanch, and once you release the pressure, the color should return to normal within 2 seconds.
In this context, the options given are:
A) Congestion
B) Hyperthermia
C) Hypertension
D) Impaired circulation
The correct conclusion the nurse should be concerned about is D) Impaired circulation .
Here's why:
What : Impaired circulation means that blood flow to the tissues is not sufficient. This can be due to several factors, such as blocked blood vessels or damage to the vascular system.
Why : When blood flow is reduced, the color return to the nailbed or skin takes longer because the blood is not being replenished quickly enough.
How : This is clinically significant because it might indicate serious underlying conditions like peripheral artery disease.
Who : Nurses or medical professionals monitor capillary refill as part of physical assessments to identify circulation problems early on.
None of the other options typically relate to prolonged capillary refill time:
Congestion would usually relate to excess fluid, particularly in respiratory conditions.
Hyperthermia relates to elevated body temperature.
Hypertension (high blood pressure) does not typically cause prolonged capillary refill unless it leads to circulatory issues.
Therefore, impaired circulation is the primary concern here.
