The nurse is providing discharge teaching to an older patient hospitalized for treatment of venous leg ulcers. What instructions should the nurse include in the teaching plan? (Select all that apply.)
The patient should eat a diet high in protein and vitamins A and C.
The patient should keep their legs elevated when sitting or lying down.
The patient should maintain as much bed rest as possible.
The patient should inspect their ankles daily for areas of darkening skin.
The patient should apply intermittent cold compresses four times daily.
Correct Answer : A,B,D
Choice A rationale
A diet high in protein and vitamins A and C can help promote wound healing. Protein is essential for tissue repair, and vitamins A and C play crucial roles in wound healing and immune function.
Choice B rationale
Keeping legs elevated when sitting or lying down can help reduce swelling and improve blood circulation, which is beneficial for healing venous leg ulcers.
Choice C rationale
Maintaining as much bed rest as possible is not typically recommended for patients with venous leg ulcers. Physical activity and movement can help improve blood circulation, which is beneficial for healing venous leg ulcers.
Choice D rationale
Inspecting ankles daily for areas of darkening skin can help detect early signs of worsening venous leg ulcers. Early detection and treatment can prevent complications and promote healing.
Choice E rationale
Applying intermittent cold compresses four times daily is not typically recommended for venous leg ulcers. Cold compresses can constrict blood vessels and reduce blood flow to the area, which may hinder the healing process.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Guillain-Barre syndrome is a disorder in which the body’s immune system attacks the nerves, causing weakness and tingling, usually starting in the legs and hands. A loss of sensation, especially at the T-8 spinal level, could indicate that the syndrome is progressing, potentially leading to paralysis. This would require immediate intervention by the nurse to prevent further complications.
Correct Answer is C
Explanation
C. Double vision.Double vision, or diplopia, can indicatephenytoin toxicity, which is a serious condition that may lead to impaired vision and increased risk of falls or injuries. This side effect suggests that the patient may be experiencing adverse reactions to the medication, necessitating prompt evaluation and intervention, such as checking serum phenytoin levels and possibly adjusting the medication regimen
.The other options do not require immediate intervention:
- A. Chronic insomniais not a critical side effect of phenytoin and may be managed with lifestyle modifications or further assessment.
- B. Puffy, bleeding gumsare common side effects associated with phenytoin (gingival hyperplasia) but are not immediately life-threatening.
- D. Blood pressure 100/78 mm Hgis within normal limits and does not indicate a need for urgent action
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