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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Transesophageal echocardiography is a diagnostic procedure that involves inserting a probe into the esophagus to obtain detailed images of the heart. In some cases, an access line may be initiated in the femoral artery to monitor blood pressure during the procedure and administer medications if needed. Informing the client about this aspect of the procedure helps ensure that they are aware of what to expect and can provide informed consent.
Let's go through the other options and explain why they are not the most appropriate actions:
Instruct the client to drink 1 L of water before the test: This action is not necessary for transesophageal echocardiography. Drinking water before the test is typically done for certain abdominal or pelvic ultrasound examinations to provide better visualization. However, for TEE, the probe is inserted into the esophagus, and drinking water is not required.
Administer intravenous (IV) benzodiazepines and opioids: The administration of intravenous benzodiazepines and opioids is not a routine part of preparing a client for TEE. The need for sedation or analgesia during the procedure would be determined based on the individual client's condition and level of discomfort.
Inform the client that the client will remain on bed rest following the procedure: While some post-procedure instructions may be given to the client, such as avoiding eating or drinking until the effects of sedation wear off, informing the client that they will remain on bed rest following the procedure is not a specific requirement for TEE. Post-procedure instructions can vary depending on the individual client's condition and the healthcare provider's recommendations.
Correct Answer is C
Explanation
Enalapril (Vasotec) is an angiotensin-converting enzyme (ACE) inhibitor medication commonly used to treat hypertension. One of the potential side effects of ACE inhibitors is hyperkalemia, which is an elevated level of potassium in the blood. Therefore, it is generally recommended for patients taking ACE inhibitors to avoid excessive intake of high-potassium foods.
The charge nurse should intervene because advising the client to increase their dietary intake of high-potassium foods contradicts the precautions associated with taking enalapril. Consuming high-potassium foods while taking this medication can potentially lead to an increased risk of hyperkalemia, which can have serious health consequences.
Let's review the other statements made by the nurse:
"Make an appointment with the dietitian for teaching": This is an appropriate statement as it encourages the client to seek professional guidance on dietary management of hypertension. A dietitian can provide valuable information on healthy eating habits and strategies to reduce blood pressure.
"Check your blood pressure at home at least once a day": This is also an appropriate statement as it promotes self-monitoring of blood pressure, which is important for clients with hypertension. Regular monitoring helps the client track their progress and detect any changes that may require medical attention.
"Move slowly when moving from lying to sitting to standing": This is a correct statement as it advises the client to practice orthostatic precautions. ACE inhibitors, including enalapril, can cause orthostatic hypotension, a drop in blood pressure upon standing. Moving slowly can help prevent dizziness and falls.
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