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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A rationale

A fasting blood glucose level of 135 mg/dL is above the diagnostic threshold for diabetes. However, it is not the exact threshold value.

Choice B rationale

A fasting blood glucose level of 140 mg/dL is significantly above the diagnostic threshold for diabetes.

Choice C rationale

A fasting blood glucose level of 126 mg/dL or higher on two separate tests indicates diabetes.

Choice D rationale

A fasting blood glucose level of 145 mg/dL is significantly above the diagnostic threshold for diabetes.

A. Review the results of liver function studies. B. Instruct the client to increase their water intake. C. Check the client’s weight. D. Test a sample of urine for the presence of occult blood.

Correct Answer is A

Explanation

Choice A rationale

Dark urine can be a sign of liver dysfunction, which can be a side effect of glipizide. Therefore, reviewing the results of liver function studies would be an appropriate initial action to determine if the medication is affecting the client’s liver function.

Choice B rationale

While increasing water intake can sometimes help with certain side effects of medications, it would not address the potential issue of liver dysfunction indicated by the dark urine.

Choice C rationale

Checking the client’s weight would not provide information related to the cause of the dark urine.

Choice D rationale

Testing a sample of urine for the presence of occult blood could be useful if there was a suspicion of bleeding, but it would not address the potential issue of liver dysfunction indicated by the dark urine.

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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?

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is aware that the diagnostic level of a fasting blood glucose for a client with diabetes is:

Correct Answer is C

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

A client has been taking glipizide for 6 months and reports to the nurse that their urine has become darker since starting the medication. What should be the nurse’s initial action?

Correct Answer is A

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

The nurse is preparing to administer a client’s warfarin sodium 5 mg PO at 1900. Upon entering the client’s room, the nurse finds several large, new ecchymotic areas on the client’s extremities. What should be the nurse’s initial action?

A newly admitted client has been prescribed trimethoprim-sulfamethoxazole. The nurse understands that this medication is contraindicated based on which lab result?

A patient diagnosed with diabetes has severe peripheral neuropathy resulting in numbness and reduced sensation of the feet. What intervention should the nurse teach the patient to prevent injury as a result of this complication?

A client has just returned to the surgical unit following a femoral-popliteal bypass of the right leg. In which position should the nurse place the client?

A nurse is caring for a patient who has peripheral arterial disease (PAD). What symptoms should the nurse expect to find in the early stage of the disease?

The nurse identifies the problem of Fluid Volume Excess for a patient. Which assessment finding validates this problem?

The nurse is educating a client who has been newly prescribed acarbose in addition to repaglinide for the treatment of Type 2 diabetes. Which statement made by the client indicates that the teaching has been effective?

The nurse is monitoring a client receiving gentamicin. Which of the following would the nurse assess as potential toxic effects of this medication?

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?