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The nurse caring for a patient with a leg ulcer has finished assessing the patient and is developing a problem list prior to writing a plan of care. What major nursing diagnosis might the care plan include?
- A. Risk for disuse syndrome
- B. Ineffective health maintenance
- C. Sedentary lifestyle
- D. Imbalanced nutrition: less than body requirements
Correct Answer: D
Rationale: Major nursing diagnoses for the patient with leg ulcers may include imbalanced nutrition: less than body requirements, related to increased need for nutrients that promote wound healing. Risk for disuse syndrome is a state in which an individual is at risk for deterioration of body systems owing to prescribed or unavoidable musculoskeletal inactivity. A leg ulcer will affect activity, but rarely to this degree. Leg ulcers are not necessarily a consequence of ineffective health maintenance or sedentary lifestyle.
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While assessing a patient the nurse notes that the patients ankle-brachial index (ABI) of the right leg is 0.40 . How should the nurse best respond to this assessment finding?
- A. Assess the patients use of over-the-counter dietary supplements.
- B. Implement interventions relevant to arterial narrowing.
- C. Encourage the patient to increase intake of foods high in vitamin K.
- D. Adjust the patients activity level to accommodate decreased coronary output.
Correct Answer: B
Rationale: ABI is used to assess the degree of stenosis of peripheral arteries. An ABI of less than 1.0 indicates possible claudication of the peripheral arteries. It does not indicate inadequate coronary output. There is no direct indication for changes in vitamin K intake and OTC medications are not likely causative.
A nurse working in a long-term care facility is performing the admission assessment of a newly admitted, 85-year-old resident. During inspection of the residents feet, the nurse notes that she appears to have early evidence of gangrene on one of her great toes. The nurse knows that gangrene in the elderly is often the first sign of what?
- A. Chronic venous insufficiency
- B. Raynauds phenomenon
- C. VTE
- D. PAD
Correct Answer: D
Rationale: In elderly people, symptoms of PAD may be more pronounced than in younger people. In elderly patients who are inactive, gangrene may be the first sign of disease. Venous insufficiency does not normally manifest with gangrene. Similarly, VTE and Raynauds phenomenon do not cause the ischemia that underlies gangrene.
The nurse has performed a thorough nursing assessment of the care of a patient with chronic leg ulcers. The nurses assessment should include which of the following components?
- A. Location and type of pain
- B. Apical heart rate
- C. Bilateral comparison of peripheral pulses
- D. Comparison of temperature in the patients legs
- E. Identification of mobility limitations
Correct Answer: A,C,D,E
Rationale: A careful nursing history and assessment are important. The extent and type of pain are carefully assessed, as are the appearance and temperature of the skin of both legs. The quality of all peripheral pulses is assessed, and the pulses in both legs are compared. Any limitation of mobility and activity that results from vascular insufficiency is identified. Not likely is there any direct indication for assessment of apical heart rate, although peripheral pulses must be assessed.
A nurse is assessing a new patient who is diagnosed with PAD. The nurse cannot feel the pulse in the patients left foot. How should the nurse proceed with assessment?
- A. Have the primary care provider order a CT.
- B. Apply a tourniquet for 3 to 5 minutes and then reassess.
- C. Elevate the extremity and attempt to palpate the pulses.
- D. Use Doppler ultrasound to identify the pulses.
Correct Answer: D
Rationale: When pulses cannot be reliably palpated, a hand-held continuous wave (CW) Doppler ultrasound device may be used to hear (insonate) the blood flow in vessels. CT is not normally warranted and the application of a tourniquet poses health risks and will not aid assessment. Elevating the extremity would make palpation more difficult.
You are caring for a patient who is diagnosed with Raynauds phenomenon. The nurse should plan interventions to address what nursing diagnosis?
- A. Chronic pain
- B. Ineffective tissue perfusion
- C. Impaired skin integrity
- D. Risk for injury
Correct Answer: B
Rationale: Raynauds phenomenon is a form of intermittent arteriolar vasoconstriction resulting in inadequate tissue perfusion. This results in coldness, pain, and pallor of the fingertips or toes. Pain is typically intermittent and acute, not chronic, and skin integrity is rarely at risk. In most cases, the patient is not at a high risk for injury.