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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View Related questions
Correct Answer is B
Explanation
Choice A rationale
Advising the UAP to hold the thermometer securely in place for a full three minutes is unnecessary and may cause discomfort to the client. Tympanic thermometers typically provide rapid temperature readings within a few seconds.
Choice B rationale
Positive reinforcement is important for encouraging and motivating staff, it should be used appropriately. In this case, the UAP is performing the procedure correctly.
Choice C rationale
Demonstrating the correct technique for pulling the client’s auricle down and back is incorrect because the UAP is using the correct technique. For adults, the auricle should be pulled up and back.
Choice D rationale
Reminding the UAP to lubricate the thermometer before gently inserting it in the ear is not necessary for tympanic thermometers. The primary issue in this scenario is the incorrect technique for positioning the client’s auricle, so reminding about lubrication is not the most relevant intervention.
Correct Answer is ["A","C","D"]
Explanation
Choice A rationale
Decreased muscle tone, relaxed jaw muscles, and a sagging mouth are common signs that indicate a client is near death. These changes occur as the body begins to shut down and muscle control diminishes.
Choice B rationale
Clear yellow urine output is not typically associated with the end-of-life stage. As death approaches, urine output usually decreases and may become darker in color.
Choice C rationale
Altered breathing patterns, such as apnea, labored or irregular breathing, and Cheyne-Stokes respiration, are common signs that a client is nearing death. These changes in breathing patterns are due to the body’s decreasing ability to regulate respiratory function.
Choice D rationale
Congestion and increased pulmonary secretions, often referred to as the “death rattle,” are common signs that a client is near death. These noisy respirations occur as the body’s ability to clear secretions diminishes.