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 A
Explanation
Choice A rationale
The hemoglobin A1C test, also known as the HbA1C or glycated hemoglobin test, is a blood test that evaluates glycemic control over a 3-month period by measuring the glucose attached to hemoglobin. This test is commonly used to diagnose and monitor diabetes. It provides an average of your blood sugar levels over the past 2-3 months, which can help healthcare providers assess how well diabetes is being managed.
Choice B rationale
The hemoglobin A1C test does not use the level of serum protein to evaluate glycemic control. Instead, it measures the amount of glucose that is attached to the hemoglobin in your red blood cells.
Choice C rationale
The hemoglobin A1C test does not evaluate serum ketone production over several days. Ketones are produced when the body burns fat for energy, which can occur when there is not enough insulin to help your body use sugar for energy. High levels of ketones can lead to diabetic ketoacidosis, a serious condition that requires immediate medical attention.
Choice D rationale
The hemoglobin A1C test does not determine the amount of glucose attached to hemoglobin over the last seven days. Instead, it provides an average of your blood sugar levels over the past 2-3 months. -
Correct Answer is D
Explanation
Choice A rationale
While holding the warfarin and notifying the laboratory could be appropriate actions in some situations, they would not address the immediate concern of the large, new ecchymotic areas on the client’s extremities.
Choice B rationale
Administering the daily dose of warfarin and notifying the healthcare provider for a dose adjustment the next day could potentially exacerbate the bleeding risk, given the presence of the large, new ecchymotic areas.
Choice C rationale
Large, new ecchymotic areas are not expected side effects of warfarin. They could indicate a serious problem such as excessive anticoagulation.
Choice D rationale
The presence of large, new ecchymotic areas could indicate excessive anticoagulation, which is a serious complication of warfarin therapy. Therefore, holding the warfarin and notifying the healthcare provider of the assessment findings would be the most appropriate initial action.
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