A client diagnosed with peripheral arterial disease has the nursing problem of Impaired Tissue Integrity related to ischemic tissue of the legs and feet.
What is an expected outcome to include in the care plan?
The client will verbalize an understanding of appropriate foot care measures by discharge.
The client will verbalize the importance of taking anti-platelet medications by discharge.
The client will discuss exercises that promote healing of wounds prior to discharge.
The client will recognize the need for an amputation in the near future.
The Correct Answer is A
Choice A rationale
The client diagnosed with peripheral arterial disease has impaired tissue integrity related to ischemic tissue of the legs and feet. This condition is often caused by factors such as physical trauma, thermal factors, chemical injury, infection, nutritional imbalances, fluid imbalances, and altered circulation. The most appropriate outcome to include in the care plan would be for the client to verbalize an understanding of appropriate foot care measures by discharge. This is because maintaining skin integrity and providing effective wound care are crucial aspects of managing this condition. By understanding and implementing appropriate foot care measures, the client can help prevent further tissue damage, promote healing, and improve their overall quality of life.
Choice B rationale
While taking anti-platelet medications can be an important part of managing peripheral arterial disease, it may not directly address the nursing problem of impaired tissue integrity. Anti-platelet medications can help prevent blood clots and improve blood flow, but they do not directly promote wound healing or tissue regeneration.
Choice C rationale
Discussing exercises that promote healing of wounds can be beneficial for the client. However, it’s important to note that exercises should be appropriate for the client’s condition and overall health status. Overexertion or inappropriate exercises could potentially exacerbate the condition and further impair tissue integrity.
Choice D rationale
Recognizing the need for an amputation in the near future can be a realistic outcome for some clients with severe peripheral arterial disease. However, this is typically considered a last resort when all other treatment options have failed. It’s also a drastic measure that can significantly impact the client’s quality of life.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Elevating the feet for 30 minutes after walking is not specifically beneficial for a patient with peripheral arterial disease (PAD). While elevation can help with conditions like edema, it does not directly address the issues associated with PAD12.
Choice B rationale
Avoiding exercise that increases the heart rate is not the best advice for a patient with PAD. Exercise, including activities that increase heart rate, can actually be beneficial. It can help improve circulation, which is often compromised in PAD12.
Choice C rationale
Continuing to walk to the point of pain is beneficial for patients with PAD. Walking, especially at a high intensity, can help improve symptoms of PAD. It can increase blood flow and oxygen supply to the muscles, which can help manage PAD symptoms.
Choice D rationale
While it’s important to care for any ulcers that develop and seek medical attention, stopping walking altogether if a leg ulcer develops is not necessary. Walking is a low-impact activity that can help improve mobility over time.
Correct Answer is D
Explanation
Choice A rationale
The infectious agent is the pathogen that causes the disease, and the reservoir is where the infectious agent lives and multiplies. Hand washing does not directly intervene between these two links.
Choice B rationale
The mode of transmission is how the infectious agent travels to other people and places, and the portal of entry is the route by which an infectious agent enters a new host. Hand washing does not directly intervene between these two links.
Choice C rationale
The susceptible host is a person who is vulnerable to the disease, and the infectious agent is the pathogen that causes the disease. Hand washing does not directly intervene between these two links.
Choice D rationale
The portal of exit is the route by which an infectious agent escapes or leaves the reservoir, and the mode of transmission is how the infectious agent travels to other people and places. Hand washing directly intervenes between these two links by removing the infectious agent from the hands (portal of exit) and preventing its transmission to other people or surfaces.
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