What is an appropriate nursing diagnosis for Mr. Carter?
Risk for infection
Ineffective health maintenance related to knowledge deficit
Acute pain
Risk for fluid volume deficit
Increase intake of processed foods
The Correct Answer is B
Choice A reason: Risk for infection is not specific to Mr. Carter’s context unless evidence of wounds or immunosuppression exists. Hypertension management focuses on lifestyle and medication adherence, not infection, making this an incorrect nursing diagnosis compared to addressing knowledge deficits in health maintenance.
Choice B reason: Ineffective health maintenance related to knowledge deficit is appropriate for Mr. Carter, likely a hypertensive patient needing education on lifestyle changes and medication adherence. This diagnosis addresses the need for teaching to improve self-management, making it the most relevant for optimizing his hypertension control and health outcomes.
Choice C reason: Acute pain is not typically associated with hypertension unless complications like angina occur. Mr. Carter’s primary issue is managing hypertension, not pain, making this an incorrect diagnosis, as knowledge deficits in health maintenance are more relevant to his condition and care needs.
Choice D reason: Risk for fluid volume deficit is less relevant for hypertension, which often involves fluid overload. Diuretics may cause depletion, but the primary issue is health maintenance through education, making this an incorrect diagnosis compared to addressing Mr. Carter’s need for hypertension management knowledge.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Walking promotes collateral circulation in peripheral vascular disease, improving blood flow and reducing claudication. Regular exercise strengthens muscles and enhances perfusion, mitigating ischemic symptoms. This is a key instruction, as it directly addresses arterial insufficiency, supporting functional status and cardiovascular health in affected clients.
Choice B reason: Knee-length stockings may restrict blood flow in peripheral vascular disease, especially arterial insufficiency, worsening ischemia. Compression is used for venous disease, not arterial. This instruction is incorrect, as it could exacerbate symptoms, requiring teaching on avoiding tight clothing to maintain circulation.
Choice C reason: Shopping for shoes in the morning is less relevant, as foot swelling in peripheral vascular disease occurs later in the day. Properly fitted shoes are important, but walking is a more direct intervention to improve circulation, making this a less critical instruction for managing the condition.
Choice D reason: Elevating legs is appropriate for venous disease to reduce edema but may worsen arterial insufficiency in peripheral vascular disease by reducing blood flow to extremities. Walking is preferred to enhance perfusion, making leg elevation an incorrect instruction for clients with arterial pathology.
Correct Answer is ["A","C","D"]
Explanation
Choice A reason: Poikilothermia, or coolness of the limb, is one of the “6 P’s” of arterial disease, indicating reduced blood flow causing temperature drop. This is a correct choice, as it reflects ischemia in acute arterial occlusion, critical for students to recognize in assessing limb compromise.
Choice B reason: Pooling is not one of the “6 P’s” of arterial disease, which include pain, pallor, pulselessness, paresthesia, paralysis, and poikilothermia. Pooling relates to venous stasis, not arterial insufficiency, making this incorrect for inclusion in teaching about arterial disease signs.
Choice C reason: Pallor is a key “6 P’s” sign of arterial disease, indicating reduced blood flow causing skin paleness due to ischemia. This is a correct choice, as it is a critical clinical finding students must recognize in assessing acute arterial occlusion and limb ischemia.
Choice D reason: Paralysis is included in the “6 P’s” of arterial disease, signaling severe ischemia impairing muscle function. This is a correct choice, as it indicates advanced limb compromise, requiring urgent intervention, and is essential for students to understand in arterial disease assessment.
Choice E reason: Petechiae, small hemorrhagic spots, are not part of the “6 P’s” of arterial disease, which focus on ischemic signs like pallor and paralysis. Petechiae relate to bleeding disorders, making this incorrect for teaching, as it does not reflect arterial occlusion pathology.
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