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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["2"]
Explanation
Given:
Desired dose: Dextromethorphan 30 mg PO
Available concentration: Dextromethorphan oral liquid 75 mg/5 mL
To find:
Volume to administer (in mL)
Step 1: Set up the proportion
We can use the following proportion to solve the problem:
(Desired dose) / (Available concentration) = Volume to administer
Step 2: Substitute the values
Plugging in the given values, we get:
(30 mg) / (75 mg/5 mL) = Volume to administer
Step 3: Simplify
To simplify, we can invert the denominator and multiply:
(30 mg) x (5 mL / 75 mg) = Volume to administer
The "mg" units cancel out, leaving us with:
(30 x 5 mL) / 75 = Volume to administer
Step 4: Calculate
Performing the multiplication and division, we get:
150 mL / 75 = Volume to administer
2mL = Volume to administer
Correct Answer is D
Explanation
A) "Increased viral load":
An increased viral load would indicate that the HIV virus is actively replicating in the body. This suggests that the antiretroviral therapy (ART) is not effective, as it has failed to suppress the viral replication. The goal of ART is to lower the viral load to undetectable levels, indicating that the virus is well controlled.
B) "Decreased neutrophil count":
. A decreased neutrophil count (neutropenia) is not directly related to the effectiveness of ART in managing HIV. Neutropenia can occur due to various causes, such as certain medications (including some ART medications), infections, or other underlying conditions. While neutropenia could be a side effect of ART, it does not directly reflect the effectiveness of HIV treatment. Monitoring CD4-T-cell counts and viral load is a better indicator of ART effectiveness.
C) "Decreased white blood cell count":
. A decreased white blood cell count (leukopenia) is also not an indicator of ART effectiveness. While some ART medications may lead to a decrease in white blood cell count, especially in the early stages of treatment, a decrease in the white blood cell count is not a measure of how well the therapy is controlling HIV. The effectiveness of ART is primarily assessed by the viral load and CD4-T-cell count.
D) "Increased CD4-T-cell count":
. CD4-T-cell count is a critical marker for monitoring the immune system's function in patients with HIV. CD4-T-cells are a type of T lymphocyte (white blood cell) that are targeted and destroyed by the HIV virus. A higher CD4-T-cell count indicates that the immune system is recovering and functioning better, which is a sign that the ART is effective in controlling the virus. Ideally, ART should result in a higher CD4-T-cell count and lower viral load, showing that the treatment is effectively suppressing the virus and preserving the immune system.
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