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

Answer and Explanation

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.

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Correct Answer is ["A","C","E"]

Explanation

A. Client with restricted activity - Patients with limited mobility are at a higher risk for pressure ulcers because they are unable to change positions easily, leading to prolonged pressure on certain body parts.

B. Client who can ambulate - Patients who can ambulate have the ability to shift their body weight and change positions, reducing the risk of prolonged pressure on specific areas. Ambulation can improve circulation and reduce the risk of pressure ulcers

C. Client with a cast - Clients with casts are often limited in their ability to move or change positions, making them susceptible to pressure ulcers in areas where the cast creates pressure points on the skin.

D. Client with good nutrition - Proper nutrition is essential for overall health, including skin health. Adequate nutrition promotes wound healing and tissue repair. Good nutrition is not a risk factor for pressure ulcers; in fact, it can contribute to preventing them by maintaining healthy skin.
E. Client with urinary and fecal incontinence - Incontinence can lead to moisture on the skin, making it more susceptible to breakdown. Prolonged exposure to moisture, especially in the presence of urine or feces, can increase the risk of pressure ulcer development.

A. Sedentary lifestyle B. Long-term use of diuretics C. Prolonged stress D. Obesity

Correct Answer is A

Explanation

A. Sedentary lifestyle - Lack of weight-bearing exercise and physical activity is a significant risk factor for the development of osteoporosis. Weight-bearing exercises help maintain bone density and strength. Sedentary individuals are more prone to osteoporosis.

B. Long-term use of diuretics - Long-term use of certain medications, such as corticosteroids, can increase the risk of osteoporosis. Diuretics are not typically associated with osteoporosis risk, although some medications can affect bone health.

C. Prolonged stress - Chronic stress can have negative effects on overall health, but it is not a direct risk factor for osteoporosis.

D. Obesity - Obesity is generally considered a protective factor against osteoporosis. Individuals with higher body weight tend to have stronger bones due to the mechanical load placed on the bones, reducing the risk of osteoporosis.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse understands that certain patients are more susceptible to pressure ulcer development. Which clients should the nurse identify as being at an increased risk for this health problem? Select all that apply.

Correct Answer is ["A","C","E"]

Explanation

A nurse in a provider's office is collecting a health history from a client who is at risk for primary osteoporosis. Which of the following findings is a risk factor for the development of osteoporosis?

Correct Answer is A

Explanation

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