A nurse is collecting data from a client who has diabetes mellitus.
The nurse should ask which of the following to determine the client's ability to provide foot self-hygiene?

Do you have any problems taking care of your feet?

Do you go barefoot at home?

Have you noticed any problems with foot swelling?

Have you had a problem with ingrown toenails?

Answer and Explanation

The Correct Answer is A

Choice A rationale

Asking if there are any problems taking care of feet directly assesses the client’s ability to perform foot self-hygiene. It opens up discussion about specific difficulties the client may face, such as flexibility, vision, or dexterity issues.

Choice B rationale

Asking if the client goes barefoot at home is related to foot safety but does not directly assess their ability to perform foot self-hygiene. It's important for preventing injuries and infections, especially in clients with diabetes.

Choice C rationale

Inquiring about foot swelling helps identify potential complications related to diabetes but does not address the client's ability to perform foot self-care.

Choice D rationale

Asking about problems with ingrown toenails is specific to a common issue in diabetic foot care but does not provide a comprehensive assessment of the client’s ability to maintain foot hygiene.

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Correct Answer is C

Explanation

Choice A rationale

Reminding the client that they must receive the medication as prescribed may increase their anxiety and does not address the fear of needles. It is essential to consider the client's emotional state and explore alternative solutions.

Choice B rationale

Telling the client not to worry because the pain will be temporary does not validate their fear or provide a solution to their anxiety about needles. It is important to address the client's concerns empathetically.

Choice C rationale

Requesting a change in the medication route to PO addresses the client's fear of needles directly and provides an alternative method of administration. This approach considers the client's comfort and preferences while ensuring they receive the necessary medication.

Choice D rationale

Asking one of the client's loved ones to encourage them to receive the IM medication may help, but it does not address the underlying fear of needles. It is essential to find a solution that directly addresses the client's anxiety.

A. Pad bony prominences before applying a restraint. B. Tie the ends of the restraint to the client's bed rail. C. Use a square knot to secure the client's restraint to the bed. D. Observe the client's skin integrity every 2 hr. E. Ensure that 2 fingers can be placed between the restraint and the client.

Correct Answer is ["A","D","E"]

Explanation

Choice A rationale

Padding bony prominences helps prevent skin breakdown and pressure ulcers, which are critical considerations when using restraints to avoid additional complications for the client.

Choice B rationale

Tying restraints to the bed rail is unsafe because it can lead to injury if the bed rail is moved. Restraints should be tied to the bed frame to prevent accidental harm.

Choice C rationale

Using a square knot for restraints is inappropriate as it is difficult to untie quickly in an emergency. Quick-release knots are recommended for safety and efficiency.

Choice D rationale

Observing the client's skin integrity every 2 hours is essential to detect early signs of skin breakdown and take preventive actions to ensure the client's comfort and safety.

Choice E rationale

Ensuring that two fingers can fit between the restraint and the client ensures that the restraint is not too tight, allowing for circulation and reducing the risk of injury.

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A nurse is collecting data from a client who has diabetes mellitus.The nurse should ask which of the following to determine the client's ability to provide foot self-hygiene?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is receiving detoxification treatment for an opioid use disorder.As the nurse is preparing to administer a methadone IM injection, the client tells the nurse, "I am afraid of needles.”. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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Correct Answer is ["A","D","E"]

Explanation

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A nurse is collecting data from a client who has diabetes mellitus.
The nurse should ask which of the following to determine the client's ability to provide foot self-hygiene?