The nurse is planning teaching for a client diagnosed with peripheral neuropathy. What should the nurse include in this teaching?
Avoid hand and foot massages.
Use a mirror to inspect feet daily.
Increase medication for pain as necessary.
Set the water heater at 120°F.
The Correct Answer is B
A) Avoid hand and foot massages: This statement may not be accurate. Gentle massages can sometimes help with circulation and comfort for individuals with peripheral neuropathy. However, caution should be exercised to avoid injury, as the sensation may be diminished.
B) Use a mirror to inspect feet daily: This is an essential teaching point. Clients with peripheral neuropathy often have decreased sensation in their feet, making it difficult to notice injuries or sores. Using a mirror allows them to check for any signs of injury or changes that could lead to complications, such as infections or ulcers.
C) Increase medication for pain as necessary: While managing pain is important, the client should be advised to consult with their healthcare provider before making any changes to their medication regimen. Self-adjusting medication could lead to unintended side effects or complications.
D) Set the water heater at 120°F: This is not advisable for someone with peripheral neuropathy, as they may not have normal temperature sensation. A lower setting is recommended to prevent burns, as the individual may not feel when the water is too hot.
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Correct Answer is C
Explanation
A) Listen for another minute just to be sure: While it is important to confirm findings, simply listening for another minute may not provide enough time to accurately assess bowel sounds, as they can be infrequent or absent in certain conditions.
B) Contact the physician as this is a surgical emergency: Not hearing bowel sounds for a minute is not immediately indicative of a surgical emergency. It’s essential to gather more information before escalating the situation.
C) Auscultate for another 4 minutes: This is the appropriate action, as the nurse should auscultate for a total of 5 minutes (1 minute initially and then 4 more minutes) to adequately assess bowel sounds. This duration allows for the detection of normal, hypoactive, or absent bowel sounds, which can provide critical information about the client’s gastrointestinal function.
D) Listen posteriorly for enhanced bowel sounds: While listening from different positions may sometimes help, the standard practice is to listen for an appropriate duration before changing techniques. Auscultating for a longer period is more clinically relevant in this scenario.
Correct Answer is C
Explanation
A) +10: This score does not exist on the muscle function grading scale, which typically ranges from 0 to 5. Using +10 could confuse the assessment and misrepresent the client's strength.
B) +4: This score indicates good strength against some resistance but not full strength. It suggests that the client has nearly complete function but may still have some limitations in range or strength.
C) +5: This score signifies full muscle strength and complete range of motion in a joint without any limitations. A score of +5 is what you would expect for a client demonstrating full strength, indicating optimal muscle function.
D) +1: This score indicates trace muscle contraction with minimal movement, which is far from the full strength described in the question. It suggests severe weakness and would not apply in this case.