Author Question: The nurse identifies the nursing diagnosis for a client as ineffective peripheral tissue perfusion ... (Read 107 times)

storky111 · **on:** Jul 22, 2018

The nurse identifies the nursing diagnosis for a client as ineffective peripheral tissue perfusion related to decreased arterial flow to extremities.

Which of the following measures should the nurse instruct the client to do to improve blood flow? 1. Cross the legs at the knees when seated.
2. Elevate the feet while reclining.
3. Position with the extremities dependent.
4. Use a heating pad to increase warmth.

Question 2

The nurse is talking with a client who is participating in a nursing research project on the unit regarding wound care. The nurse determines that the client understands the goal of the research when the client states:

1. This research will have no bearing on my care..
2. I will be paid to give my responses..
3. I will be helping to validate nursing care..
4. Nursing care is based solely on research..

ebe · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

3. Position with extremities dependent.

Rationale:
Positioning with the extremities dependent is correct because gravity promotes arterial flow to the dependent extremity, increasing tissue perfusion. Crossing the legs at the knees when seated is not recommended because this position compresses partially obstructed arteries and impairs blood flow. Elevating the feet while reclining is not recommended because elevating the feet works against gravity and will further impede blood flow. Using a heating pad to increase warmth is not recommended because external heating devices could increase the risk of burns in a client with impaired circulation and the consequent decreased sensation.

Answer to Question 2

3. I will be helping to validate nursing care..

Rationale:
Improving nursing care and establishing the profession's credibility are two goals of nursing research. The research project will probably change the normal routine of the client's care. Clients do not receive pay for participating in research. Nursing care is based on intuition and the experience of the nurse as well as research.