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
Recording the client’s daily weight is not the most immediate concern for a terminally ill client who is weak, mouth breathing, and refusing anything to eat or drink. The priority is to address the client’s comfort and hydration.
Choice B rationale
Maintaining the client in high Fowler’s position may help with breathing but does not directly address the issue of dry mucous membranes.
Choice C rationale
Keeping mucous membranes moist is crucial for the comfort of a terminally ill client who is mouth breathing and refusing anything to eat or drink. This intervention helps prevent dryness and discomfort.
Choice D rationale
Reporting any change in urine color is important but not the most immediate concern for a terminally ill client in this condition. The priority is to address the client’s comfort and hydration.
Correct Answer is D
Explanation
Choice A rationale
Beginning the collection the next day is not necessary. The 24-hour urine collection can be started immediately with the next void. Delaying the collection may cause unnecessary inconvenience and prolong the client’s hospital stay.
Choice B rationale
Emptying the sample into the 24-hour container is incorrect because the first urine sample should be discarded to ensure that the collection starts with an empty bladder. Including the initial sample would result in inaccurate measurement of creatinine clearance.
Choice C rationale
Observing the sample for sediment is not relevant to the collection process for creatinine clearance. The focus should be on ensuring accurate timing and collection of all urine produced within the 24-hour period.
Choice D rationale
Starting the collection with the next void is the correct action. The 24-hour urine collection should begin with an empty bladder, and the first urine of the day is discarded. The time is noted, and all subsequent urine is collected for the next 24 hours. This ensures accurate measurement of creatinine clearance.