# Situation: A 70-year-old man who has smoked for 50 years comes to the Rural Health Unit (RHU) because of calf pain when walking. He has type 2 diabetes and hypertension. He says the calf pain starts after walking about 200 meters and goes away after 2 to 3 minutes of standing still. At night his feet ache until he hangs them over the side of the bed. Which explanation should the nurse give for the relief he gets from hanging his feet down?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=629894  
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> subject: Nursing Practice III — Care of Clients with Problems in Surgery, Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory and Immunologic Response, Cellular Aberrations

## 문제

Situation: A 70-year-old man who has smoked for 50 years comes to the Rural Health Unit (RHU) because of calf pain when walking. He has type 2 diabetes and hypertension.

He says the calf pain starts after walking about 200 meters and goes away after 2 to 3 minutes of standing still. At night his feet ache until he hangs them over the side of the bed. Which explanation should the nurse give for the relief he gets from hanging his feet down?

## 보기

1. Lowering the feet lets pooled blood in the veins drain back to the heart
2. Hanging the feet stretches the calf muscles and eases the night cramps
3. Gravity helps arterial blood flow down into his narrowed leg arteries **✔ 정답**
4. Lowering the feet reduces swelling that is pressing on the leg nerves

**정답: 3**

## 해설

Calf pain with walking that is relieved by rest is intermittent claudication, and foot pain at night relieved by dangling is ischemic rest pain; both come from narrowed leg arteries. Hanging the legs lets gravity help arterial blood reach the ischemic tissue, whereas venous disease is relieved by elevation.

## 심화 해설

Clinical context The presentation combines two classic patterns of chronic lower-extremity ischemia. Exertional calf pain that begins after a predictable walking distance and resolves within minutes of stopping is intermittent claudication. Nocturnal foot pain that forces the patient to hang the leg over the bedside is ischemic rest pain. Both arise from the same underlying process: fixed narrowing of the leg arteries that limits oxygen delivery to working or resting tissue [1][3].

Why hanging the feet down relieves ischemic rest pain In peripheral arterial disease, atherosclerotic plaque reduces the arterial lumen. When the patient lies supine, the heart must pump against gravity to perfuse the feet, and the already low distal perfusion pressure becomes insufficient to meet even resting metabolic demand. Dangling the legs adds hydrostatic pressure from the column of blood, which increases arterial perfusion pressure in the foot and temporarily improves blood flow through the narrowed vessels. This gravity-assisted increase in arterial inflow is what relieves the ischemic pain [1].

Why the other options are incorrect Option 1 describes venous pooling and venous return, which is the opposite problem. In venous insufficiency, blood pools in the lower leg because valves fail; elevation, not dependency, promotes drainage back to the heart. Option 2 attributes the relief to muscle stretching, but ischemic rest pain is not a muscle cramp caused by spasm or electrolyte imbalance. Option 4 suggests edema compressing nerves, yet the pain here is ischemic, not neuropathic or compressive. Key point! Venous disease improves with leg elevation; arterial ischemic rest pain improves with leg dependency.

| Feature | Arterial insufficiency (PAD) | Venous insufficiency |
| --- | --- | --- |
| Typical pain | Intermittent claudication; ischemic rest pain at night | Aching, heaviness, worse with prolonged standing |
| Relieving position | Dangling the legs (gravity increases arterial inflow) | Elevating the legs (gravity aids venous return) |
| Skin findings | Cool, pale, shiny, hair loss, thickened nails | Warm, brownish discoloration, edema, stasis dermatitis |
| Pulses | Diminished or absent | Usually palpable unless severe edema |

Clinical significance for nursing assessment This patient’s risk profile is typical: 50 pack-year smoking history, type 2 diabetes, and hypertension all accelerate atherosclerosis [1]. The walking distance of 200 meters before pain onset helps quantify functional limitation and can be tracked over time to monitor disease progression or response to conservative therapy [3]. Watch out! Ischemic rest pain signals more advanced disease than claudication alone and is a clear indication for revascularization evaluation, whereas claudication alone is generally managed conservatively first .

Why this matters for the licensure exam Questions often ask you to differentiate arterial from venous disease using the position that relieves pain. Remember the direction of gravity’s benefit: arterial disease wants blood to flow down into the leg, so dependency helps; venous disease wants blood to flow back up to the heart, so elevation helps. The nocturnal pattern of hanging the feet over the bed is a hallmark of ischemic rest pain and should prompt immediate vascular assessment rather than reassurance or symptomatic treatment alone [1].References (research sources)

- [1]Intermittent claudication.Research articleBick C (2003) · DOI: 10.7748/ns2003.07.17.42.45.c3414

- [3]Current Management of Intermittent Claudication.Research articleStonko DP, Hicks CW (2023) · DOI: 10.1016/j.yasu.2023.04.009

## 임상 시나리오

Ischemic Rest Pain: Why Dangling HelpsGravity-assisted arterial perfusion in PAD
In peripheral arterial disease, narrowed leg arteries reduce distal perfusion. When supine, the heart must pump against gravity, and perfusion pressure may fall below resting tissue demand, causing ischemic rest pain.

Dangling the legs adds hydrostatic pressure from the blood column, increasing arterial perfusion pressure in the foot by approximately 20–30 mmHg. This temporarily improves blood flow through narrowed vessels and relieves pain.

CautionDo not confuse with venous insufficiency, where blood pools in the lower leg. Venous pain is relieved by elevation, not dependency. Assess for PAD risk factors: smoking, diabetes, hypertension, age over 70.

## 핵심 개념

- **Intermittent claudication** — Calf pain with walking that is relieved by rest, caused by narrowed leg arteries limiting oxygen delivery to working muscle.
- **Ischemic rest pain** — Nocturnal foot pain due to severe arterial insufficiency, often relieved by dangling the leg to improve perfusion.
- **Peripheral arterial disease** — Atherosclerotic narrowing of leg arteries that reduces distal perfusion pressure and causes exertional or rest pain.
- **Hydrostatic pressure** — Pressure exerted by a fluid column; dangling the legs increases arterial perfusion pressure in the foot.
- **Venous insufficiency** — Failure of venous valves causing blood pooling in the lower leg, relieved by elevation rather than dependency.

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