The nurse notes ulcerations on the surfaces of the patient's toes and assesses this as an indication of:
1. skin breakdown from pressure.
2. nutritional deficit.
3. venous stasis.
4. arterial stasis.
4
Arterial stasis ulcers on the tips of patient's toes are indicators of arterial insufficiency. This is a serious and probably progressive disorder that leads to further risk of impaired skin in-tegrity.
You might also like to view...
The nurse caring for small-for-gestational-age (SGA) infants assesses them for attainment of outcomes related to nursing diagnoses. Which assessment finding best demonstrates attainment of priority outcomes?
A. Body temperature of 97.5 °F (36.4 ° C) B. Gains weight regularly C. Parents visit daily D. Skin remains intact
The nurse recognizes that preventive programs in schools must be stepped up to attempt to prevent violence, especially __________
Fill in the blank(s) with correct word
A patient recently diagnosed with herpes simplex 2 asks how to best manage the lesions. What information should be given to the patient?
1. The use of soap should be restricted. 2. A solution of 50% rubbing alcohol and 50% water can be used to clean the lesions. 3. Wearing nylon panties will reduce discomfort. 4. Warm soaks may be used to cleanse the area.
An older adult patient has an open, draining wound on the lower medial aspect of the right leg. The skin surrounding the wound is reddish brown with surrounding erythema and edem
a. Based on this information, the nurse edits the patient's care plan to include impaired skin integrity: a. related to altered venous circulation. b. peripheral related to arterial insufficiency. c. related to diabetic neuropathy. d. open wound related to pressure ulcer.