A nurse assesses a young female client who is prescribed tazarotene.
Which query should the nurse ask prior to starting this therapy?

Choice A rationale

This question directly assesses for intermittent claudication, a hallmark symptom of peripheral artery disease (PAD). A decrease in walking distance before the onset of pain (claudication) over time indicates a progressive worsening of the arterial stenosis. This is a critical piece of information for staging the disease and evaluating the effectiveness of treatment.

Choice B rationale

The type of terrain (uphill, downhill, flat) can influence the workload on the leg muscles and therefore affect the onset of pain. However, this is a secondary factor. The most important clinical indicator for the progression of PAD is a change in the pain-free walking distance over time, regardless of the terrain.

Choice C rationale

Suggesting swimming instead of walking is a recommendation for a different exercise modality, but it does not provide diagnostic information about the client's current condition. The purpose of the initial assessment is to gather objective data on the progression of the disease, not to provide alternative lifestyle recommendations at this stage.

Choice D rationale

Asking about pain medication usage is important for pain management, but it does not provide specific information about the severity or progression of the peripheral artery disease itself. The primary symptom of PAD is pain upon exertion, and the key assessment is to determine the distance a person can walk before experiencing this pain, as well as if that distance is changing. .

Choice A rationale

A Braden Scale score of 9 indicates a high risk for pressure injury. Requesting a referral to a registered dietitian nutritionist is an evidence-based intervention because poor nutrition, particularly protein and calorie deficiency, is a significant risk factor for skin breakdown and impaired wound healing.

Choice B rationale

Keeping the head of the bed raised no more than 45 degrees is an evidence-based practice to prevent pressure injuries. This position reduces the risk of shear and friction forces on the sacrum, which can lead to tissue damage and pressure ulcer formation.

Choice C rationale

Performing perineal cleansing every 2 hours is not an evidence-based intervention for a Braden Scale score of 9. Frequent cleansing can cause excessive moisture, which macerates the skin and increases the risk of breakdown. Cleansing should be done as needed, not on a rigid schedule.

Choice D rationale

Daily skin assessment is a fundamental and evidence-based intervention for all clients at risk for pressure injuries. A Braden score of 9 signifies a high-risk client, and a daily head-to-toe skin assessment is crucial for early detection of erythema or other signs of skin breakdown.