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
Knowing how many popsicles are available is not relevant to the nurse’s assessment. The focus should be on the content and preparation of the popsicles to ensure they meet the clear liquid diet requirements.
Choice B rationale
The color and flavor of the gelatin used in the popsicles are not as important as ensuring the popsicles meet the clear liquid diet requirements. The nurse should focus on the preparation and content of the popsicles.
Choice C rationale
Ensuring the popsicles are completely frozen is important to adhere to the clear liquid diet recommendation. If the popsicles are not completely frozen, they may contain solid particles or ingredients that could worsen the child’s condition.
Choice D rationale
Whether the popsicles contain pulp or fruit is important to determine if they meet the clear liquid diet requirements. Popsicles with pulp or fruit do not qualify as clear liquids and could worsen the child’s condition.
Correct Answer is A
Explanation
Choice A rationale
Ensuring the bevel of the needle is pointing up is crucial when administering an intradermal injection. This technique allows the medication to be deposited just below the surface of the skin, creating a small bleb or wheal. This is important for the proper absorption and effectiveness of the medication.
Choice B rationale
Massaging the site gently after injection is not recommended for intradermal injections. Massaging can cause the medication to spread into the subcutaneous tissue, which can affect the accuracy of the test results or the effectiveness of the medication.
Choice C rationale
Holding the syringe perpendicular to the skin is not appropriate for intradermal injections. Intradermal injections should be administered at a 5 to 15-degree angle to ensure the medication is deposited just below the surface of the skin.
Choice D rationale
Selecting the upper arm as the injection site is not the best practice for intradermal injections. The preferred sites for intradermal injections are the inner surface of the forearm and the upper back below the scapula.