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 ["84.1"]
Explanation
Weightinkg=185÷2.2≈84.1
Calculate the dose of enoxaparin:
The prescribed dose is 1 mg/kg.
Doseinmg=Weightinkg×Doseperkg
Doseinmg=84.1×1≈84.1
The nurse should administer 84.1 mg of enoxaparin.
Correct Answer is D
Explanation
A. Lordosis: Lordosis is an inward curvature of the spine, commonly seen in the lower back (lumbar spine) or neck (cervical spine). It creates a swayback appearance. Lordosis is not typically associated with osteoporosis.
B. Scoliosis: Scoliosis is a sideways curvature of the spine, creating an "S" or "C" shape. While scoliosis can occur in people of all ages, it is not directly caused by osteoporosis.
C. Ankylosis: Ankylosis refers to the stiffening or fusion of joints, often due to inflammation and progressive loss of function. It is not a spinal deformity associated with osteoporosis.
D. Kyphosis: Kyphosis is a forward rounding of the back, leading to a hunched or humpbacked posture. It commonly affects the upper back (thoracic spine) and is associated with osteoporosis, especially in older adults. When the bones in the spine weaken due to osteoporosis, they can compress and collapse, leading to the development of kyphosis. This condition is sometimes referred to as a dowager's hump when it occurs in older women.
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