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
Providing client-focused information is important, but it does not confirm that the client has understood the critical information. The nurse needs to ensure that the client has comprehended the instructions.
Choice B rationale
Observing the client’s body language can provide some insight into their understanding, but it is not a reliable method to confirm comprehension. The nurse needs to use a more direct approach to ensure understanding.
Choice C rationale
Asking the client for learning feedback is the most important strategy to confirm that the client is learning the critical information. This method allows the nurse to assess the client’s understanding and clarify any misconceptions. It ensures that the client has comprehended the instructions and can apply the information correctly.
Choice D rationale
Reinforcing key points with the client is important, but it does not confirm that the client has understood the critical information. The nurse needs to ensure that the client has comprehended the instructions.
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.