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.

Choice D rationale

The symptoms described - edema, severe pain, paresthesia, and tightness of the operative limb

- are indicative of Compartment Syndrome. This is a serious condition that can occur after surgery, where increased pressure within one of the body’s compartments results in insufficient blood supply to the area. It requires immediate treatment to prevent permanent damage.

Choice A rationale

While wound infection is a possible post-operative complication, it would typically present with symptoms such as redness, increased pain at the wound site, purulent discharge, and possibly fever. The symptoms described do not specifically indicate a wound infection.

Choice B rationale

Internal bleeding could cause pain and swelling, but it would likely also present with signs of shock, such as low blood pressure, increased heart rate, and altered mental status. The symptoms provided do not clearly indicate internal bleeding.

Choice C rationale

Graft rupture is a serious complication that could potentially cause severe pain and swelling. However, it would also likely cause significant hemodynamic instability, including hypotension and tachycardia. The symptoms described are more indicative of Compartment Syndrome.