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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 D

Explanation

Choice A rationale

Recording a palpable systolic pressure of 90 mm Hg without further action would likely underestimate the true systolic pressure. The nurse should inflate the cuff to a higher pressure to obtain an accurate measurement.

Choice B rationale

Releasing the manometer valve immediately would lead to deflating the cuff and potentially missing the opportunity to obtain an accurate blood pressure measurement.

Choice C rationale

Documenting the absence of the radial pulse is important, but it is also crucial to ensure that blood pressure measurements are obtained correctly. Further action is needed to obtain an accurate measurement.

Choice D rationale

Inflating the blood pressure cuff to 120 mm Hg is the correct action. When the radial pulse becomes unpalpable during cuff inflation, the cuff should be inflated to a higher pressure (usually 20-30 mm Hg above the point where the radial pulse disappears) and then slowly deflated while palpating for the return of the radial pulse.

Correct Answer is A

Explanation

Choice A rationale

Smoking cessation is the most important lifestyle modification for preventing and managing cardiac disease. Smoking is a major modifiable risk factor that can cause atherosclerosis, hypertension, arrhythmias, thrombosis, and myocardial infarction. Quitting smoking has a more direct effect on improving the function and structure of the blood vessels and heart.

Choice B rationale

Regular exercise is a beneficial lifestyle modification for preventing and managing cardiac disease, but it is not the most important one. While exercise helps in maintaining a healthy weight, reducing blood pressure, and improving overall cardiovascular health, smoking cessation has a greater impact on reducing the risk of cardiovascular events and mortality.

Choice C rationale

A low-fat diet is a useful lifestyle modification for preventing and managing cardiac disease, but it is not the most important one. Although a low-fat diet helps in lowering cholesterol levels and reducing the risk of heart disease, smoking cessation has a stronger influence on lowering the levels of cholesterol and inflammation in the blood.

Choice D rationale

Stress reduction is a helpful lifestyle modification for preventing and managing cardiac disease, but it is not the most important one. While stress reduction techniques such as relaxation exercises, meditation, and mindfulness can be beneficial for heart health, addressing smoking cessation is more urgent for individuals with a family history of cardiac disease.

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