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 D

Explanation

Increasing regular weight-bearing activities can help prevent osteoporosis by stimulating bone formation and improving muscle strength. Weight-bearing activities are those that make your bones and muscles work against gravity, such as walking, jogging, dancing, or lifting weights.

Choice A is wrong because protecting the client’s bones with strict bedrest can actually increase the risk of osteoporosis by reducing bone density and muscle mass. Bedrest should be avoided unless medically necessary.

Choice B is wrong because providing the client with assisted range of motion exercises twice daily is not enough to prevent osteoporosis. While these exercises can help maintain joint mobility and flexibility, they are not weight bearing and do not stimulate bone formation.

Choice C is wrong because decreasing the amount of calcium in the client’s diet can also increase the risk of osteoporosis. Calcium is an essential mineral for bone health and adults need 700mg a day, which can be obtained from foods such as dairy products, leafy green vegetables, tofu, and dried fruit. Vitamin D is also important for bone health as it helps the body absorb calcium.

A. Place the patient in a side-lying position only. B. Massage bony prominences. C. Use positioning devices such as foam wedges. D. Keep the head of the bed elevated higher than 30 degrees. E. Inspect skin every shift.

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.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who is at risk for developing osteoporosis asks what can be done to decrease the risk of actually developing the disorder. Which intervention would be the most beneficial for this client?

Correct Answer is D

Explanation

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

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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?