The nurse is caring for a client who is diagnosed with an arterial insufficiency ulcer. The nurse should plan interventions to address which priority issue?
Chronic pain
Impaired skin integrity
Risk for injury
Ineffective tissue perfusion
The Correct Answer is D
A. Chronic pain - Chronic pain is a concern for the client, but addressing the underlying issue of ineffective tissue perfusion will help alleviate pain by promoting healing and reducing tissue damage.
B. Impaired skin integrity - Impaired skin integrity is a result of ineffective tissue perfusion. By addressing perfusion issues, skin integrity can be improved as tissues receive adequate oxygen and nutrients for healing.
C. Risk for injury - While clients with arterial insufficiency ulcers are at risk for injury, the immediate concern is addressing the ineffective tissue perfusion to prevent complications related to poor circulation, such as tissue necrosis and infection.
D. Ineffective tissue perfusion- Arterial insufficiency ulcers are caused by inadequate blood flow to the tissues. The priority issue for a client with an arterial insufficiency ulcer is ineffective tissue perfusion. Due to decreased blood flow, tissues do not receive enough oxygen and nutrients, leading to delayed wound healing, tissue damage, and potential complications. Interventions should focus on improving circulation, promoting vasodilation, and enhancing perfusion to facilitate wound healing and prevent further tissue damage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D","E"]
Explanation
A. Malunion: Malunion happens when a fractured bone heals in an improper position, leading to deformity and functional impairment. While it is a concern, it typically develops over time during the healing process and is not an immediate early complication that the nurse would monitor for in the acute phase following a fracture.
B. Compartment syndrome: Compartment syndrome is a serious condition that can occur after an injury, such as a fracture. When there is increased pressure within a muscle compartment, it can lead to reduced blood flow, potentially causing tissue damage and nerve injury. Prompt recognition and intervention are crucial to prevent complications.
C. Fat embolism: Fat embolism occurs when fat particles from the bone marrow or other sources enter the bloodstream, often after a long bone fracture or major trauma. These particles can travel to the lungs and other organs, causing respiratory distress, confusion, and other symptoms. Fat embolism is a significant concern in orthopedic trauma patients and requires careful monitoring.
D. Deep vein thrombosis (DVT): DVT is the formation of blood clots in deep veins, usually in the legs. Patients with fractures, especially those immobilized for extended periods, are at increased risk for DVT. If a clot dislodges and travels to the lungs, it can cause a pulmonary embolism, which is a life-threatening complication.
E. Pulmonary emboli: Pulmonary emboli occur when blood clots, often originating from DVT, travel to the lungs and block pulmonary arteries. This condition can lead to sudden difficulty breathing, chest pain, and even cardiac arrest. Pulmonary embolism is a medical emergency and requires immediate intervention.
Correct Answer is B
Explanation
A. Use Echinacea to manage joint pain:
Echinacea is a natural supplement, but its effectiveness in managing joint pain related to osteoarthritis is not well-established. It's important for individuals to consult their healthcare provider before using any supplements, as they may interact with medications or have other adverse effects.
B. Maintain a recommended body weight.
Maintaining a healthy body weight is an important recommendation for managing osteoarthritis. Excess weight puts additional stress on weight-bearing joints, such as knees and hips, which can worsen osteoarthritis symptoms. Losing weight, if necessary, or maintaining a healthy weight can help reduce joint pain and improve mobility in individuals with osteoarthritis.
C. Apply ice to the joint before exercising:
Applying ice can help reduce inflammation and provide pain relief, but it's typically used after exercising or during acute flare-ups, not necessarily before exercising. Heat is often recommended before exercise to warm up the joint and improve flexibility.
D. Reduce the amount of purine in the diet:
This recommendation is more relevant for managing gout, a different type of arthritis caused by the buildup of uric acid crystals in the joints. Purine-rich foods can trigger gout attacks but are not directly related to osteoarthritis. Osteoarthritis is primarily related to wear and tear of the joints over time.
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