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 B

Explanation

A. GERD:
Gastroesophageal reflux disease (GERD) typically presents with symptoms such as heartburn, regurgitation, and chest pain. It is not related to head trauma or the symptoms described, such as severe headache, vomiting, seizure, and unresponsiveness. GERD is not associated with a fall or neurological events, making it an unlikely diagnosis in this scenario.

B. Hemorrhagic stroke:
A hemorrhagic stroke is a strong suspicion in this case, given the client’s recent fall, the report of a severe headache, vomiting, followed by a seizure and loss of consciousness. These are classic symptoms of increased intracranial pressure, which may result from bleeding in the brain, such as from a hemorrhagic stroke. The client’s hypertension (248/120 mmHg) further increases the risk of a hemorrhagic stroke, particularly in someone on long-term Warfarin, which increases the risk of bleeding. The seizure and unresponsiveness are concerning signs of significant brain injury, and a CT scan or MRI would be essential for confirming this diagnosis.
C. Septic shock:
Septic shock presents with hypotension, fever, tachycardia, and signs of infection. While the client’s elevated temperature (99.2 F) and pulse (102/min) are abnormal, they are not out of proportion to what would be expected with a head injury and potential hemorrhage. Septic shock is unlikely without signs of infection or systemic inflammatory response. The presence of a seizure, headache, and vomiting after trauma suggests a neurological emergency, not sepsis.

D. Absence seizure:
Absence seizures are brief, non-convulsive seizures characterized by a sudden interruption of consciousness, often with a blank stare and lack of motor activity. These seizures are typically seen in younger individuals and are not associated with symptoms such as a severe headache, vomiting, or unresponsiveness following head trauma. The client’s seizure, along with other concerning signs (headache, vomiting, high blood pressure), suggests a more serious neurological event like a hemorrhagic stroke rather than a simple seizure disorder.

A. Walking is contraindicated and bed rest as much as possible is recommended B. Dangle" legs on the side of the bed several times per day C. Avoid sitting or standing for prolonged periods D. Elevate legs above heart level for 20-30 minutes. 4-5 times per day E. Use compression stockings to decrease swelling

Correct Answer is ["C","D","E"]

Explanation

A) Walking is contraindicated and bed rest as much as possible is recommended:
. Walking is actually highly recommended for patients with chronic venous insufficiency (CVI). Gentle, regular physical activity, such as walking, helps improve circulation and reduce the risk of blood pooling in the lower extremities. Bed rest is not typically recommended unless the patient has severe symptoms like ulcers or active infection. In fact, staying active can promote better venous return and prevent worsening of CVI.

B) Dangle legs on the side of the bed several times per day:
. Dangling the legs can exacerbate venous stasis (blood pooling in the veins), which worsens symptoms of chronic venous insufficiency. Instead of dangling the legs, patients should focus on elevating the legs to reduce swelling and improve venous return. Dangle the legs only if advised by a healthcare provider for specific reasons, such as short periods of time to encourage blood flow after immobility.

C) Avoid sitting or standing for prolonged periods:
. One of the key recommendations for managing chronic venous insufficiency is to avoid prolonged sitting or standing. Remaining in one position for too long can cause blood to pool in the lower extremities, leading to increased swelling, pain, and discomfort. It’s important to encourage frequent position changes and movement, such as standing up or walking around if sitting, or sitting down to rest if standing for prolonged periods.

D) Elevate legs above heart level for 20-30 minutes, 4-5 times per day:
. Elevating the legs above heart level is a key intervention for patients with chronic venous insufficiency. This helps reduce swelling by promoting venous return and decreasing the pressure in the veins. Elevating the legs for 20-30 minutes, several times a day (4-5 times) can help alleviate symptoms and prevent further complications, such as ulcers and skin changes.

E) Use compression stockings to decrease swelling:
. Compression stockings are a cornerstone of managing chronic venous insufficiency. They help improve venous return, prevent blood from pooling in the lower legs, and reduce swelling. The stockings should be properly fitted and worn throughout the day (except when sleeping) to provide continuous support and minimize the risk of complications associated with CVI, such as venous ulcers.

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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

Correct Answer is B

Explanation

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Correct Answer is ["C","D","E"]

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