A nurse is caring for a client on an IV infusion of heparin.
What actions does this nurse include in the client's plan of care? (Select all that apply.)

Choice A rationale

While medication cost can be a barrier to adherence, it doesn't directly address the client's misconception about the disease itself. Focusing on this aspect may be premature and might not resolve the client's core belief that treatment is unnecessary without symptoms.

Choice B rationale

This statement provides accurate and crucial scientific information. Hypertension is often called the "silent killer" because it typically has no symptoms until it causes significant end-organ damage. Explaining this concept directly addresses the client's flawed reasoning about medication adherence.

Choice C rationale

This response is dismissive and inaccurate. Most people with hypertension do not experience severe morning headaches, and this statement might mislead the client into thinking their lack of symptoms is a sign of good health, thereby reinforcing their decision not to take medication.

Choice D rationale

This response uses scare tactics, which can be counterproductive. While kidney failure is a potential consequence of untreated hypertension, a more educational and less confrontational approach is generally more effective for promoting long-term adherence to a medical regimen.

Choice A rationale

Abrasive pumice stones should be avoided in peripheral vascular disease. The reduced blood flow and neuropathy in this condition make the skin more fragile and susceptible to injury. Abrasions or small cuts from a pumice stone can lead to non-healing ulcers and serious infections due to poor circulation.

Choice B rationale

Wearing cheap flip-flops is not a good practice. They offer inadequate support and protection. Clients with peripheral vascular disease often have reduced sensation (neuropathy), making them unaware of foot injuries from ill-fitting or unprotected footwear. Properly fitting, supportive shoes are essential for foot protection.

Choice C rationale

Keeping feet dry, especially between the toes, prevents maceration and fungal infections like athlete's foot. In peripheral vascular disease, even minor skin breaks can become entry points for pathogens, leading to severe infections and ulcers that are difficult to heal due to compromised circulation.

Choice D rationale

Applying lotion is beneficial for dry skin but it should not be applied between the toes. Applying lotion between the toes can create a moist environment that promotes fungal growth. Fungal infections can lead to skin breakdown, which is a significant risk for ulceration and infection in clients with poor circulation.

Choice E rationale

Washing feet in room-temperature water is critical for client safety. Clients with peripheral vascular disease often have sensory deficits (neuropathy) and may not be able to accurately perceive temperature. Using hot water could easily cause burns, which in a client with poor circulation can lead to severe, non-healing wounds.

Choice F rationale

Daily inspection of the feet is a cornerstone of self-care for peripheral vascular disease. Clients should be taught to look for any cuts, sores, blisters, or redness. Early detection of these issues allows for prompt intervention before they can progress into serious, difficult-to-treat infections or ulcers.