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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","E"]

Explanation

Choice A rationale

Asking the healthcare provider for a mild sedative for bedtime may not be the best first-line approach for improving sleep. Sedatives can have side effects and may lead to dependency. Non-pharmacological interventions are generally preferred for managing sleep disturbances in older adults.

Choice B rationale

Taking an afternoon nap to make up for missed sleep can disrupt the sleep-wake cycle and make it harder to fall asleep at night. It is generally recommended to avoid napping during the day to improve nighttime sleep quality.

Choice C rationale

Drinking a mixture of warm water, whiskey, and honey at bedtime is not a recommended practice for improving sleep. Alcohol can disrupt sleep patterns and lead to poor sleep quality. It is better to avoid alcohol before bedtime.

Choice D rationale

Establishing a regular time for going to bed and getting up helps regulate the body’s internal clock and improve sleep quality. Consistency in sleep schedules is a key factor in promoting healthy sleep habits.

Choice E rationale

Avoiding caffeinated beverages late in the day is important for improving sleep. Caffeine is a stimulant that can interfere with the ability to fall asleep and stay asleep.

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.

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