The nurse is caring for a client with a history of neuropathy who reports increasing numbness and tingling in the lower extremities. Which problem should the nurse determine is the priority for promoting foot care at this time?
Self-care deficit.
Impaired physical mobility.
Risk for infection.
Risk for impaired skin integrity.
The Correct Answer is D
Choice A rationale
While a self-care deficit may be a concern for clients with neuropathy, it is not the primary issue related to foot care. The priority is to prevent skin breakdown and injuries that can lead to more serious complications.
Choice B rationale
Impaired physical mobility is a common issue for clients with neuropathy, but it is not the primary concern for foot care. The focus should be on preventing skin breakdown and injuries.
Choice C rationale
Risk for infection is an important consideration, but it is secondary to the risk of impaired skin integrity. Preventing skin breakdown and injuries is the first step in reducing the risk of infection.
Choice D rationale
Risk for impaired skin integrity is the priority for promoting foot care in clients with neuropathy. Neuropathy can compromise the ability to detect injuries or wounds on the feet, leading to unnoticed wounds that can become infected and cause serious complications.
Preventing skin breakdown and injuries is crucial for maintaining foot health.
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Correct Answer is C
Explanation
Choice A rationale
Inspecting crutches to ensure rubber tips are intact is important for safety, but it does not indicate an understanding of proper crutch walking technique. Proper crutch walking involves more than just equipment inspection.
Choice B rationale
Practicing bicep and triceps isometric exercises can help strengthen the muscles needed for crutch walking, but it does not directly demonstrate an understanding of the correct crutch gait. The focus should be on the actual technique of using the crutches.
Choice C rationale
Bearing body weight on the palms of hands during the crutch gait is the correct behavior that indicates an understanding of proper crutch walking. This technique helps distribute weight appropriately and prevents strain on the underarms, which can cause nerve damage and discomfort.
Choice D rationale
Progressing to foot touchdown and weight bearing of the affected leg is not appropriate for a three-point gait, which is used when the client should not bear any weight on the affected leg. This choice indicates a misunderstanding of the correct crutch walking technique for this specific gait.
Correct Answer is C
Explanation
Choice A rationale
Recording the client’s daily weight is not the most immediate concern for a terminally ill client who is weak and mouth breathing. The priority is to address comfort and hydration.
Choice B rationale
Maintaining the client in high Fowler’s position can help with breathing but does not directly address the issue of dry mucous membranes due to mouth breathing and refusal to eat or drink.
Choice C rationale
Keeping mucous membranes moist is crucial for comfort and preventing complications such as dryness and cracking, which can lead to infections. This intervention directly addresses the client’s symptoms and promotes comfort.
Choice D rationale
Reporting any change in urine color is important but not the most immediate concern for a terminally ill client who is weak and mouth breathing. The priority is to address comfort and hydration.