A nurse is caring for a client with peripheral arterial disease (PAD). Which of the following interventions should the nurse include in the plan of care?

Encourage strict bed rest with tuning and repositioning every 2 hours.

Have the client dangle" their legs several times per day and when pain occurs,

Have the client elevate their legs above heart level when pain occurs

Have the client use ice packs to relieve lower extremity pain.

Answer and Explanation

The Correct Answer is B

A) "Encourage strict bed rest with turning and repositioning every 2 hours":
. For clients with peripheral arterial disease (PAD), strict bed rest is not recommended unless the client is in severe pain or experiencing complications like ulcers or gangrene. In PAD, exercise and mobility are essential for improving blood flow and reducing symptoms. Prolonged immobility could worsen circulation and lead to complications like muscle atrophy. Therefore, encouraging gentle movement and activity, like walking or repositioning, is typically more beneficial than prolonged bed rest.

B) "Have the client 'dangle' their legs several times per day and when pain occurs":
. For clients with PAD, dangling the legs can be helpful in alleviating pain and discomfort. When the client dangles their legs, gravity helps to increase blood flow to the lower extremities, which can provide temporary relief from symptoms like intermittent claudication (pain caused by insufficient blood flow). It is important to balance this with the advice to avoid elevating the legs, as elevating them above the heart level may decrease arterial perfusion, worsening symptoms.

C) "Have the client elevate their legs above heart level when pain occurs":
. Elevating the legs above the heart level in clients with PAD may worsen symptoms. In PAD, blood flow to the legs is already compromised, and elevating the legs above the heart can further reduce arterial blood flow to the lower extremities, increasing pain and discomfort. Instead, dangling the legs or lying flat with the legs at heart level is generally better for improving circulation.

D) "Have the client use ice packs to relieve lower extremity pain":
. Applying ice packs is not recommended for clients with PAD, as cold can cause vasoconstriction, further reducing blood flow to already compromised tissues. Cold therapy may increase pain and lead to tissue damage in individuals with reduced circulation. The nurse should instead focus on strategies that promote blood flow, such as encouraging gentle exercise, dangling the legs, or using warmth (in some cases) to improve circulation.

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Correct Answer is D

Explanation

A. "You probably have a gastrointestinal infection":
This statement is incorrect. A positive result on the enzyme-linked immunosorbent assay (ELISA) indicates the presence of antibodies to HIV, which suggests exposure to the virus. It does not point to a gastrointestinal infection. HIV is a viral infection that primarily affects the immune system, not the gastrointestinal system. Misleading the client in this way would delay proper care and understanding of their health status.

B. "You are confirmed to be infected with the HIV virus.":
A positive ELISA test result does not automatically confirm an HIV diagnosis. ELISA is a screening test that detects HIV antibodies, but it can sometimes produce false-positive results. A positive ELISA result must be confirmed with a more specific confirmatory test, such as the Western blot test. Therefore, it would be premature to tell the client that they are "confirmed" to be infected with HIV without further confirmatory testing.

C. "This is a good result, which means you do not have HIV.":
This statement is also incorrect. A positive ELISA test result does not mean that the client does not have HIV. In fact, it indicates potential exposure to the virus. However, because the result is a screening test, it must be followed up with confirmatory testing. Telling the client that this is a "good result" would be misleading and could cause confusion or delay in appropriate care.

D. "Your result will need to be confirmed with a Western blot test.":
This is the correct response. The Western blot test is the confirmatory test used to verify a positive result from the ELISA. If the ELISA result is positive, the client should be informed that further testing, such as the Western blot, is needed to confirm the diagnosis of HIV infection. It is important to explain that the ELISA is a screening tool, and a positive result does not mean a definitive diagnosis without confirmation. This helps to set realistic expectations and ensures the client receives the appropriate follow-up care.

A. Cardiac dysrhythmias B. Hypertension C. 53 and 54 heart sounds D. Fluid overload

Correct Answer is B

Explanation

A. Cardiac dysrhythmias:
While cardiac dysrhythmias can occur after a stroke, especially in the acute phase due to changes in autonomic regulation and increased sympathetic tone, they are not a direct compensatory response to increase cerebral blood flow. Dysrhythmias, such as atrial fibrillation, can occur as a result of stroke but are not a physiological response to attempts by the body to increase cerebral perfusion.

B. Hypertension:
Hypertension is a common cardiovascular response in the acute phase of a stroke. The body increases blood pressure to enhance cerebral perfusion and ensure that oxygen and nutrients are delivered to the brain, especially if there is impaired blood flow due to a clot or hemorrhage. This compensatory mechanism helps maintain adequate cerebral blood flow to areas at risk of ischemia. Therefore, hypertension is the most likely cardiovascular sign that the nurse would observe in response to a stroke, and it is a key sign that needs to be closely monitored and managed.

C. 53 and 54 heart sounds:
The presence of 53 and 54 heart sounds, also known as extra heart sounds, such as S3 and S4, may indicate heart failure, volume overload, or diastolic dysfunction. While these sounds can be associated with certain cardiovascular conditions, they are not a typical sign observed in the acute phase of a stroke as the body attempts to increase cerebral blood flow. These heart sounds are more related to heart conditions rather than stroke-induced changes in cerebral perfusion.

D. Fluid overload:
Fluid overload, although a potential complication in stroke patients (especially if they are given excessive IV fluids or have renal issues), is not a primary compensatory mechanism for increasing cerebral blood flow. Fluid overload could exacerbate other conditions, like increased intracranial pressure or pulmonary edema, but it does not directly serve the purpose of improving cerebral perfusion during a stroke. Hypertension, on the other hand, is a direct response to try to maintain cerebral blood flow.

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A nurse is caring for a client with peripheral arterial disease (PAD). Which of the following interventions should the nurse include in the plan of care?

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Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is B

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