A client with uncontrolled diabetes mellitus reports experiencing numbness and tingling in their feet that disrupts their sleep.The nurse explains this as a nerve disorder known as peripheral neuropathy.
Which statement by the client indicates they understand the cause of this condition?
“The nerves just go to sleep when I lie down because no message gets from my brain to the spinal cord.”.
“The nerve damage may occur for unknown reasons in any individual.”.
“The older I get, the less blood flows to my feet.”.
“The elevated blood sugar from my diabetes can cause underlying nerve damage.”.
The Correct Answer is D
Choice A rationale
This statement is incorrect. Nerves do not “go to sleep.”. Peripheral neuropathy in diabetes is caused by damage to the nerves as a result of high blood sugar levels over time.
Choice B rationale
This statement is incorrect. While nerve damage can occur due to various reasons, in the context of diabetes, it is primarily due to prolonged high blood sugar levels.
Choice C rationale
This statement is incorrect. Age and blood flow to the feet are not the primary causes of peripheral neuropathy in diabetes. The primary cause is prolonged high blood sugar levels.
Choice D rationale
This statement is correct. Prolonged high blood sugar levels in diabetes can cause damage to the peripheral nerves, leading to peripheral neuropathy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D","E"]
Explanation
Choice A rationale: Clients with epilepsy are at high risk of injury from falls during seizures due to sudden loss of consciousness or motor control. Climbing ladders increases the risk of severe trauma, including head injuries and fractures, if a seizure occurs at height. The American Epilepsy Society recommends avoiding elevated surfaces without safety measures. Neurological unpredictability in epilepsy necessitates minimizing exposure to high-risk environments to prevent secondary injuries during seizure episodes.
Choice B rationale: Swimming alone is contraindicated for clients with epilepsy due to the risk of drowning if a seizure occurs in water. A partner can provide immediate assistance, ensuring airway patency and preventing submersion. The CDC and Epilepsy Foundation emphasize supervised aquatic activity. Seizures may cause loss of consciousness or muscle control, making it impossible for the individual to self-rescue. Even brief seizures can lead to aspiration or hypoxic injury if not promptly addressed by a nearby observer.
Choice C rationale: Driving restrictions for clients with epilepsy vary by jurisdiction, but most guidelines, including those from ATI and the Epilepsy Foundation, recommend a seizure-free period of 6 to 12 months before resuming driving. This is based on the risk of sudden incapacitation while operating a vehicle, which endangers both the driver and the public. A 3-month seizure-free period is insufficient and not evidence-based. Neurological stability must be demonstrated over a longer duration to ensure safety.
Choice D rationale: Power tools pose a significant hazard to individuals with epilepsy due to the potential for sudden seizure activity during operation. These tools often involve sharp, fast-moving components that can cause severe injury if control is lost. The Occupational Safety and Health Administration (OSHA) advises against unsupervised use of such equipment by individuals with seizure disorders. Seizure unpredictability necessitates avoiding machinery that requires continuous attention and motor coordination to prevent traumatic injuries.
Choice E rationale: During a seizure, especially a generalized tonic-clonic seizure, it is critical to gently guide the client to the floor to prevent injury from falling. This position helps reduce the risk of head trauma and allows for safer seizure progression. The floor provides a stable surface, minimizing the chance of secondary injury. The nurse should also clear the area of sharp objects and cushion the head to protect the client during convulsions, as recommended by seizure first aid protocols.
Choice F rationale: Positioning a client on their back during postictal recovery is contraindicated due to the risk of airway obstruction. Seizures often result in decreased consciousness, increased oral secretions, or vomiting. The supine position can lead to aspiration or hypoxia. Instead, the recovery position—lying on the side—facilitates drainage of secretions and maintains airway patency. The American Red Cross and Epilepsy Foundation recommend side-lying recovery to reduce respiratory complications and promote safe postictal recovery.
Correct Answer is C
Explanation
Choice A rationale
Administering acetaminophen by mouth for pain control is important, but it is not the first intervention that should be implemented for a client who has had a traumatic fall. Pain management is crucial, but it is not the immediate priority in this situation.
Choice B rationale
Performing a thorough health history is a part of the nursing assessment, but it is not the first intervention in an acute situation such as a traumatic fall. Immediate physical needs and potential injuries need to be addressed first.
Choice C rationale
Preparing for a STAT non-contrast CT scan is the correct answer. After a traumatic fall, it is crucial to quickly assess for potential injuries, especially to the brain. A CT scan can help identify any immediate life-threatening conditions such as bleeding in the brain.
Choice D rationale
Inserting an indwelling urinary catheter to monitor urine output is an intervention that may be necessary depending on the client’s condition, but it is not the first intervention to be implemented after a traumatic fall.
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