A client diagnosed with peripheral arterial disease has the nursing problem of Impaired Tissue Integrity related to ischemic tissue of the legs and feet.
What is an expected outcome to include in the care plan?
The client will verbalize an understanding of appropriate foot care measures by discharge.
The client will verbalize the importance of taking anti-platelet medications by discharge.
The client will discuss exercises that promote healing of wounds prior to discharge.
The client will recognize the need for an amputation in the near future.
The Correct Answer is A
Choice A rationale
The client diagnosed with peripheral arterial disease has impaired tissue integrity related to ischemic tissue of the legs and feet. This condition is often caused by factors such as physical trauma, thermal factors, chemical injury, infection, nutritional imbalances, fluid imbalances, and altered circulation. The most appropriate outcome to include in the care plan would be for the client to verbalize an understanding of appropriate foot care measures by discharge. This is because maintaining skin integrity and providing effective wound care are crucial aspects of managing this condition. By understanding and implementing appropriate foot care measures, the client can help prevent further tissue damage, promote healing, and improve their overall quality of life.
Choice B rationale
While taking anti-platelet medications can be an important part of managing peripheral arterial disease, it may not directly address the nursing problem of impaired tissue integrity. Anti-platelet medications can help prevent blood clots and improve blood flow, but they do not directly promote wound healing or tissue regeneration.
Choice C rationale
Discussing exercises that promote healing of wounds can be beneficial for the client. However, it’s important to note that exercises should be appropriate for the client’s condition and overall health status. Overexertion or inappropriate exercises could potentially exacerbate the condition and further impair tissue integrity.
Choice D rationale
Recognizing the need for an amputation in the near future can be a realistic outcome for some clients with severe peripheral arterial disease. However, this is typically considered a last resort when all other treatment options have failed. It’s also a drastic measure that can significantly impact the client’s quality of life.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Diabetes mellitus can lead to several chronic complications, including retinopathy, which can cause blindness. Regular eye exams are crucial for early detection and treatment of diabetic retinopathy. Therefore, scheduling and keeping appointments for annual eye exams is an important part of managing diabetes.
Choice B rationale
While adequate fluid intake is generally important for overall health, it is not specifically effective in preventing kidney damage in patients with diabetes mellitus. Kidney damage in diabetes, also known as diabetic nephropathy, is caused by high blood sugar levels over time, not by dehydration.
Choice C rationale
Regular checks of cardiac enzymes are not a standard part of diabetes management. Cardiac enzymes are typically checked in the context of suspected heart disease or a heart attack, not as a routine measure in diabetes care.
Choice D rationale
While regular foot care is important in diabetes to prevent complications such as foot ulcers and infections, podiatry exams every 3 months are not typically necessary unless the patient has a history of foot problems or a high risk of foot complications.
Correct Answer is C
Explanation
Choice A rationale
Changes to achieve low HDL and high LDL levels are not recommended. In fact, the opposite is desired. High levels of HDL (good cholesterol) and low levels of LDL (bad cholesterol) are beneficial for overall health and can help prevent cardiovascular complications associated with diabetes.
Choice B rationale
Self-monitoring of blood glucose is important for managing diabetes, but a fasting plasma glucose level of 118 mg/dL does not necessarily indicate the need for regular self-monitoring. This level is slightly elevated and may indicate prediabetes, but further testing would be needed for a definitive diagnosis.
Choice C rationale
Maintenance of a healthy weight is beneficial for everyone, but it’s particularly important for individuals with prediabetes or diabetes. Achieving and maintaining a healthy weight can help regulate blood glucose levels and prevent or delay the progression of prediabetes to diabetes.
Choice D rationale
Utilizing carbohydrate counting to match insulin intake is a strategy used in the management of diabetes. However, a fasting plasma glucose level of 118 mg/dL, while slightly elevated, does not necessarily indicate the need for insulin therapy or carbohydrate counting. Further testing would be needed to confirm a diagnosis of diabetes.
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