The nurse is caring for a client who is diagnosed with an arterial insufficiency ulcer. The nurse should plan interventions to address which priority issue?

Chronic pain

Impaired skin integrity

Risk for injury

Ineffective tissue perfusion

Answer and Explanation

The Correct Answer is D

A. Chronic pain - Chronic pain is a concern for the client, but addressing the underlying issue of ineffective tissue perfusion will help alleviate pain by promoting healing and reducing tissue damage.

B. Impaired skin integrity - Impaired skin integrity is a result of ineffective tissue perfusion. By addressing perfusion issues, skin integrity can be improved as tissues receive adequate oxygen and nutrients for healing.

C. Risk for injury - While clients with arterial insufficiency ulcers are at risk for injury, the immediate concern is addressing the ineffective tissue perfusion to prevent complications related to poor circulation, such as tissue necrosis and infection.

D. Ineffective tissue perfusion- Arterial insufficiency ulcers are caused by inadequate blood flow to the tissues. The priority issue for a client with an arterial insufficiency ulcer is ineffective tissue perfusion. Due to decreased blood flow, tissues do not receive enough oxygen and nutrients, leading to delayed wound healing, tissue damage, and potential complications. Interventions should focus on improving circulation, promoting vasodilation, and enhancing perfusion to facilitate wound healing and prevent further tissue damage.

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Correct Answer is D

Explanation

The findings of pale and cool skin on the lower legs, along with small circular ulcers on the soles of the feet, are indicative of arterial insufficiency. Arterial insufficiency occurs when there is a decreased blood flow to the extremities, often due to conditions such as atherosclerosis or peripheral arterial disease. This reduced blood flow can result in pale and cool skin, as well as the development of ulcers, which are typically round and have well-defined borders. It is essential to assess and manage arterial insufficiency promptly to prevent complications like tissue necrosis and gangrene.

A. Remove heel boots B. Reposition every 3 hours C. Apply cornstarch to keep the skin dry D. Provide high protein diet

Correct Answer is A

Explanation

A. Remove heel boots:
Heel boots are often used to protect the heels from pressure ulcers. However, it's important to assess the skin regularly and remove heel boots periodically to inspect the skin underneath. Leaving them on continuously without proper inspection can cause moisture buildup, leading to skin breakdown.

B. Reposition every 3 hours
Repositioning the client every 3 hours is a crucial intervention to prevent skin breakdown, especially in individuals at risk, such as older adults. Prolonged pressure on specific areas of the body can lead to pressure ulcers or bedsores. Regular repositioning helps relieve pressure on vulnerable areas, improving circulation and reducing the risk of skin breakdown.

C. Apply cornstarch to keep the skin dry:
While it's essential to keep the skin clean and dry, using cornstarch can sometimes lead to moisture retention, especially in skin folds. Excess moisture can contribute to skin breakdown and fungal infections. Instead, proper hygiene practices and the use of moisture-wicking products are recommended.

D. Provide high protein diet:
Adequate nutrition, including a high-protein diet, is essential for overall skin health and healing. Protein is necessary for tissue repair and regeneration. While a balanced diet is crucial for overall health, it is not a specific intervention solely focused on maintaining skin integrity.

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The nurse is caring for a client who is diagnosed with an arterial insufficiency ulcer. The nurse should plan interventions to address which priority issue?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

A nurse is caring for an older adult client who is at risk for skin breakdown. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin?

Correct Answer is A

Explanation

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