The nurse has written a plan of care for a client diagnosed with peripheral arterial insufficiency. Which intervention is the most appropriate for this diagnosis?

Elevate the legs and arms above the heart when resting.

Encourage the client to engage in a moderate amount of exercise.

Encourage extended periods of sitting or standing.

Discourage walking in order to limit pain.

Answer and Explanation

The Correct Answer is B

The most appropriate intervention for a client diagnosed with peripheral arterial insufficiency is: Encourage the client to engage in a moderate amount of exercise. Peripheral arterial insufficiency is a condition characterized by reduced blood flow to the extremities, typically the legs, due to narrowed or blocked arteries. Regular exercise is an important component of managing peripheral arterial insufficiency. Exercise helps improve circulation, promote collateral blood vessel development, and increase the distance a client can walk before experiencing pain (intermittent claudication). Therefore, encouraging the client to engage in a moderate amount of exercise, such as walking, under healthcare provider guidance is crucial.]

The other options are not appropriate interventions for peripheral arterial insufficiency:

Elevating the legs and arms above the heart when resting: While elevation can be beneficial for certain conditions, such as reducing swelling in venous insufficiency, it is not the primary intervention for peripheral arterial insufficiency. Elevation alone does not improve arterial blood flow and may not effectively address the underlying circulatory issues.

Encouraging extended periods of sitting or standing: Prolonged sitting or standing can further restrict blood flow and exacerbate symptoms in clients with peripheral arterial insufficiency. Encouraging regular movement and avoiding prolonged immobility is important to maintain adequate circulation.

Discouraging walking in order to limit pain: While walking may cause pain or discomfort in clients with peripheral arterial insufficiency (intermittent claudication), it is important to encourage walking as part of an exercise regimen. Walking helps improve symptoms over time and promotes overall cardiovascular health.

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Correct Answer is C

Explanation

The most important finding to report to the health care provider would be the serum potassium level of 3.0 mEq. This is an extremely low potassium level (normal range is typically 3.5-5.0 mEq/L), which can indicate a potentially life-threatening condition called hypokalemia. Furosemide (Lasix) is a diuretic medication that can cause potassium loss in the urine, and a low potassium level can lead to serious cardiac and muscle abnormalities. It is crucial to report this finding promptly to the health care provider for appropriate intervention and monitoring.

Blood glucose level of 175 mg/dL: While an elevated blood glucose level can be a concern, especially for individuals with diabetes, it is not the most critical finding in this situation. The client's primary concern is hypertension, and the administration of IV furosemide is aimed at managing blood pressure. The elevated blood glucose level should still be addressed and monitored, but it is not as urgent as the low potassium level.

Orthostatic systolic BP decrease of 12 mm Hg: Orthostatic hypotension refers to a significant decrease in blood pressure upon standing up. While it is important to assess and manage orthostatic changes, a decrease of 12 mm Hg in systolic blood pressure alone may not be considered clinically significant. It could be a normal response for some individuals. However, if the client experiences symptoms such as dizziness or lightheadedness upon standing, further evaluation may be necessary. Nonetheless, it is not as urgent as the low potassium level.

Current blood pressure reading of 166/94 mm Hg: While this blood pressure reading indicates hypertension, it is not the most critical finding to report in this situation. The nurse is preparing to administer furosemide (Lasix), which is a medication commonly used to treat hypertension. It is expected that the blood pressure will be high before administering the medication. The goal is to monitor the blood pressure after the administration to assess the effectiveness of the medication.

A. "Have you recently taken any antihistamines?" B. "Have there been recent stressful events in your life?" C. "Did you take any acetaminophen today?" D. "Have you consistently taken your medications?"

Correct Answer is D

Explanation

Choice D: This question is crucial as it addresses the client's adherence to their prescribed medication regimen for managing high blood pressure. Consistent medication use is essential for controlling blood pressure and reducing the risk of complications associated with hypertension. The elevated blood pressure reading suggests that the current medication regimen may not be effectively controlling the client's blood pressure. By assessing medication adherence, the nurse can determine if non-adherence is contributing to the high blood pressure reading or if adjustments to the medication regimen are required.

"Have you recently taken any antihistamines?": Asking about recent antihistamine use is not directly relevant to the client's high blood pressure reading of 210/106 mm Hg. Antihistamines are medications primarily used to relieve allergy symptoms and do not typically have a signiﬁcant impact on blood pressure levels.

"Have there been recent stressful events in your life?": While stress can contribute to temporary increases in blood pressure, asking about recent stressful events is not the most critical follow-up question in this situation. The client's blood pressure reading of 210/106 mm Hg indicates a severe elevation that requires immediate attention and management beyond stress reduction alone.

"Did you take any acetaminophen today?": Acetaminophen, also known as paracetamol, is a pain reliever and fever reducer. It does not typically have a signiﬁcant effect on blood pressure. Therefore, asking about acetaminophen use is not the most relevant follow-up question for the client's high blood pressure reading.

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The nurse has written a plan of care for a client diagnosed with peripheral arterial insufficiency. Which intervention is the most appropriate for this diagnosis?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing to administer IV furosemide (Lasix) to a client with hypertension. What is the most important finding to report to the health care provider?

Correct Answer is C

Explanation

A nurse is assessing a client with a history of high blood pressure. The client's blood pressure is 210/106 mm Hg during the assessment. What follow-up question should the nurse ask?

Correct Answer is D

Explanation

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