A diabetic client presents to the acute care facility for the amputation of two gangrenous digits on her left foot.
Which type of perfusion issue has caused this condition?

Arterial insufficiency.

Stasis.

Venous insufficiency.

Varicose veins.

Answer and Explanation

The Correct Answer is A

This means that the blood flow to the affected area is reduced due to narrowed or blocked arteries. This can cause tissue death or gangrene. Diabetes can

damage the blood vessels and affect blood flow, increasing the risk of gangrene. Choice B. Stasis is wrong because it refers to a condition where blood pools in the veins of the legs, causing swelling and skin changes. It does not cause gangrene by itself.

Choice C. Venous insufficiency is wrong because it refers to a condition where the veins in the legs have problems sending blood back to the heart, causing swelling and skin ulcers. It does not cause gangrene by itself.

Choice D. Varicose veins are wrong because they are enlarged veins that may cause pain or discomfort, but do not cause gangrene by themselves.

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Correct Answer is C

Explanation

his intervention can help prevent pressure ulcers by reducing the amount of pressure on bony prominences and promoting blood circulation to the skin.

Choice A is wrong because placing the patient in a side-lying position only can increase the risk of skin breakdown by limiting the patient’s mobility and exposing the same areas to pressure. The patient should be repositioned frequently and encouraged to change positions if able.

Choice B is wrong because massaging bony prominences can cause tissue damage and increase the risk of skin breakdown by impairing blood flow to the area. Massaging should be avoided over bony prominences and areas of redness.

Choice D is wrong because keeping the head of the bed elevated higher than 30 degrees can cause shearing forces on the skin, which can lead to skin breakdown. The head of the bed should be kept at the lowest degree of elevation possible.

Choice E is wrong because inspecting skin every shift is not enough for a patient at risk for impaired skin integrity. The skin should be inspected at least every 2 hours or more frequently depending on the patient’s condition. Early detection of skin changes can help prevent further damage and promote healing.

Normal ranges for skin integrity are:

• Skin color: consistent with ethnicity and genetic background, no pallor, cyanosis, or jaundice.

• Skin moisture: dry to touch, no excessive perspiration or dryness. • Skin texture: smooth, soft, intact, with even surface.

• Skin temperature: warm to touch, no hyperthermia or hypothermia. • Skin turgor: elastic, returns to original shape after being pinched. • Skin integrity: no lesions, wounds, abrasions, or ulcers.

A. Do you have spiritual practices that are helpful to you? B. What makes you feel that your belief is correct? C. Are you part of a religious or spiritual community? D. What sustains you and keeps you going?.

Correct Answer is B

Explanation

The HOPE Tool for spiritual assessment is a questionnaire that explores the sources of hope, meaning, comfort, strength, peace, love, and connection for patients in healthcare settings. It does not ask about the correctness of one’s belief, but rather about the relevance and importance of one’s spirituality to one’s overall health and well-being. Therefore, choice B is not part of the HOPE Tool.

Choice A is wrong because it is part of the HOPE Tool. It asks about the personal spirituality and practices of the patient.

Choice C is wrong because it is part of the HOPE Tool. It asks about the organized religion or spiritual community of the patient.

Choice D is wrong because it is part of the HOPE Tool. It asks about the sources of hope or sustenance for the patient.

Normal ranges are not applicable to this question as it is not a numerical or quantitative measure.

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A diabetic client presents to the acute care facility for the amputation of two gangrenous digits on her left foot. Which type of perfusion issue has caused this condition?

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Naxlex Comprehensive Predictor Exams

The RN identifies that a client is at risk for impaired skin integrity. Which interventions should the nurse add to this client’s plan of care?

Correct Answer is C

Explanation

Correct Answer is B

Explanation

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A diabetic client presents to the acute care facility for the amputation of two gangrenous digits on her left foot.
Which type of perfusion issue has caused this condition?