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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?

A.

Self-care deficit.

B.

Impaired physical mobility.

C.

Risk for infection.

D.

Risk for impaired skin integrity.

Answer and Explanation

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 ["A","B","C","G","H"]

Explanation

Choice A rationale

Measuring vital signs at 1500 is essential because the client has a temperature of 102°F (38.9°C) at 1400, indicating a potential infection or other condition that needs monitoring.

Choice B rationale

At 1600, it is important to measure vital signs to assess the client’s response to any interventions provided for the elevated temperature.

Choice C rationale

At 1800, continuous monitoring of vital signs helps detect any changes in the client’s condition and ensures timely intervention if needed.

Choice G rationale

Measuring vital signs at 1400 provides a baseline for comparison with subsequent readings, especially given the elevated temperature.

Choice H rationale

Measuring vital signs at 2000 ensures continuous monitoring and helps detect any late changes in the client’s condition.

Correct Answer is C

Explanation

Choice A rationale


Active bowel sounds in the lower right quadrant are a normal finding and do not deviate from the established norm or expected outcome. Therefore, they do not need to be documented when charting by exception.

Choice B rationale

Contraction of the left pupil when light shines in the right eye is a normal consensual pupillary response. This is an expected finding and does not need to be documented when charting by exception.

Choice C rationale

Basilar lung sounds that are diminished in the left lung are not within normal limits and deviate from the expected outcome. This abnormal finding should be documented when charting by exception.

Choice D rationale

Capillary refill of 2 seconds in the lower right foot is a normal finding and does not deviate from the established norm or expected outcome. Therefore, it does not need to be documented when charting by exception.

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