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
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.
Correct Answer is C
Explanation
A. Hypovolemic shock: Hypovolemic shock occurs when there is a significant loss of blood or fluids in the body, leading to insufficient blood volume to maintain normal circulation. Symptoms include rapid heart rate, low blood pressure, confusion, and cold, clammy skin. While hypovolemic shock is a concern in trauma patients, the symptoms described by the client (shortness of breath and chest pain) are not typical of hypovolemic shock.
B. Fat embolism syndrome: Fat embolism syndrome occurs when fat particles are released into the bloodstream, often after a long bone fracture or trauma. These fat particles can block small blood vessels, leading to symptoms such as respiratory distress, confusion, and petechial rash (small red or purple spots under the skin). While fat embolism syndrome is a concern in patients with long bone fractures, the symptoms described by the client are more suggestive of a pulmonary embolism.
C. Venous thromboembolism (VTE): VTE refers to the formation of blood clots in the veins. Deep vein thrombosis (DVT) occurs when a blood clot forms in a deep vein, usually in the legs, while pulmonary embolism (PE) occurs when a clot breaks loose and travels to the lungs. Symptoms of PE can include sudden chest pain, shortness of breath, rapid heart rate, and cough, which may produce bloody or blood-streaked sputum. Given the client's symptoms of shortness of breath and chest pain, VTE, specifically pulmonary embolism, is a significant concern.
D. Compartment syndrome: Compartment syndrome occurs when there is increased pressure within a muscle compartment, leading to reduced blood flow and potential nerve damage. Symptoms can include severe pain, swelling, and numbness or tingling. While compartment syndrome is a complication of fractures, the symptoms described by the client (shortness of breath and chest pain) are not characteristic of compartment syndrome.
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