A nurse is caring for a client. Diagnostic Results Admission Day 1: 1100: Hemoglobin A1C: 8.1% (< 7%) Fasting glucose: 132 mg/dL (74 mg/dL – 106 mg/dL) Medical History Type 1 diabetes mellitus Hypertension Nurses' Notes Day 1 1100: Client is alert and oriented to person, place, and time. Ulceration of right great toe, partial thickness; with a wound bed that is pale with yellow slough tissue and margins that are well defined. Right foot is non-edematous, cool. Client reports pain level at 8 on a 0 to 10 pain scale when walking, and a 5 when sitting. Day 3 0930: Skin of bilateral lower extremities has decreased pigmentation, is shiny, with hair loss to mid-calf. +2 bilateral peripheral pulses, +1 posterior tibial to affected leg. Capillary refill delayed to lower extremity nail beds. Client reports pain of 6 on a 0 to10 pain scale when walking and a 2 when sitting. Pain treated with opioids PO as needed. Vital Signs Admission Day 1 1100: Temperature: 37.2deg C (98.9deg F) Heart rate: 80/min Respiratory rate: 18/min Blood pressure: 148/82 mm Hg SaO2: 99% on room air Day 3 0630: Temperature: 36.6deg C (97.9deg F) Heart rate: 76/min Respiratory rate: 16/min Blood pressure: 128/82 mm Hg SaO2: 97% on room air For each assessment finding, click to specify if the assessment finding is consistent with an arterial ulcer, a venous ulcer, or a diabetic ulcer. Each finding may support more than one disease process. Assessment Findings Arterial ulcer Venous ulcer Diabetic ulcer Defined edges Hair loss Pain at ulcer site Pale wound bed Skin cool to touch of the affected extremity History of hypertension +1 posterior tibial pulse
[Verified Answer]: A nurse is caring for a client
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