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 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.
Correct Answer is D
Explanation
A. Increase sodium intake - This is not a preventive measure for osteoporosis. High sodium intake can lead to increased calcium excretion and weaken bones.
B. Drink a cup of coffee each morning - Caffeine consumption, especially in excess, can interfere with calcium absorption and increase calcium excretion. Limiting caffeine intake is recommended for bone health. Drinking coffee in moderation is acceptable but excessive consumption should be avoided.
C. Have a bone-density scan each year - While bone-density scans (DEXA scans) are useful for diagnosing osteoporosis or assessing bone health, they are not typically recommended for young adults with a family history of osteoporosis unless there are specific risk factors present. Yearly scans are unnecessary and not cost-effective for young adults without significant risk factors.
D. Engage in weight-bearing exercise regularly - Weight-bearing exercises, such as walking, jogging, dancing, and resistance training, help to increase bone density and strength. Regular physical activity, especially weight-bearing exercises, is a recommended preventive measure against osteoporosis.
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