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 ["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
Removing dentures or other oral appliances is not the most critical intervention for a client with severe obstructive sleep apnea (OSA) who has received an opioid analgesic. The priority is to ensure airway patency.
Choice B rationale
Elevating the head of the bed to a 45-degree angle can help improve airway patency but is not as effective as applying the positive airway pressure device.
Choice C rationale
Applying the client’s positive airway pressure device (CPAP or BiPAP) is the most important intervention because it directly maintains airway patency and prevents respiratory compromise, which is crucial for a client with severe OSA2.
Choice D rationale
Putting and locking the side rails in place is important for safety but does not address the critical need to maintain airway patency in a client with severe OSA.