A nurse is teaching a female client about alcohol intake and how it affects hypertension.
The client asks if drinking two beers a night is an acceptable intake.What answer by the nurse is best?

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

An arterial ulcer is a complex wound resulting from chronic tissue ischemia. A wound care nurse possesses specialized knowledge in advanced wound management techniques, including debridement, moisture balance, and identifying appropriate dressings, which are crucial for promoting healing in these challenging, poorly perfused wounds.

Choice B rationale

While pain management is important for client comfort, it is not the most critical action. The best action is to address the underlying cause of the non-healing wound and implement specialized care that targets the specific challenges of arterial ulcers, such as poor perfusion and a high risk of infection.

Choice C rationale

Maintaining sterile technique is a standard of care to prevent infection, but it is insufficient on its own to heal an arterial ulcer. These wounds require a comprehensive approach that includes improving blood flow, debridement of non-viable tissue, and specialized dressings, which a wound care nurse can best guide.

Choice D rationale

Preparing the client for amputation is a premature and often psychologically damaging action. Amputation is a last resort after all conservative and revascularization options have been exhausted. The primary goal is to heal the ulcer through a concerted effort of specialized wound care and addressing the vascular insufficiency.