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Following admission, a client with a vascular occlusion of the right lower extremity calls the nurse and reports difficulty sleeping because of cold feet. Which of the following nursing actions should the nurse take to promote the client's comfort?

A.

Obtain a pair of slipper socks for the client.

B.

Increase the client's oral fluid intake.

C.

Rub the client's feet briskly for several minutes.

D.

Place a moist heating pad under the client's feet.

Answer and Explanation

The Correct Answer is A

A. Obtain a pair of slipper socks for the client. Slipper socks can provide warmth without applying direct heat, which is safer for clients with impaired circulation.

 

B. Increase the client's oral fluid intake. Increasing fluids does not directly address cold feet and may be contraindicated depending on the client’s condition.

 

C. Rub the client's feet briskly for several minutes. Rubbing can damage skin and tissue in clients with poor circulation and should be avoided.

 

D. Place a moist heating pad under the client's feet. Heating pads can cause burns and further impair circulation in clients with vascular issues.


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Correct Answer is D

Explanation

A. Elevated thyroid hormone levels. While amiodarone can cause thyroid dysfunction, elevated thyroid levels (hyperthyroidism) would typically present with symptoms like increased energy or restlessness.

B. Low blood glucose levels. Low blood glucose is not related to amiodarone. Symptoms of hypoglycemia include sweating, hunger, and confusion, not heat intolerance or fatigue.

C. Elevated blood glucose levels. Hyperglycemia is not a known side effect of amiodarone.

D. Low thyroid hormone levels. Amiodarone can induce hypothyroidism, which may cause fatigue and heat intolerance. Regular thyroid monitoring is recommended with long-term amiodarone use.

Correct Answer is C

Explanation

A. Advise the client to come into the office. The client needs immediate emergency intervention, not a routine office visit.

B. Advise the client to take an antacid. Chest pain unrelieved by nitroglycerin may indicate myocardial infarction; an antacid would not help.

C. Instruct the client to call 911. Persistent chest pain unrelieved by nitroglycerin warrants emergency attention due to potential heart attack.

D. Tell the client to take another nitroglycerin tablet in 15 min. The protocol allows taking an additional dose in 5 minutes, but emergency services should be called for unrelieved chest pain.

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