A nurse is gathering data from an older adult client.
Which finding should alert the nurse to a potential bladder infection?

Choice A rationale

It is important for a client with diabetes mellitus to test the temperature of the water before bathing to prevent burns. People with diabetes often have neuropathy, which can reduce their ability to feel temperature changes, especially in their extremities. Therefore, using the wrist, which is more sensitive to temperature changes, can help ensure the water is not too hot.

Choice B rationale

Applying a heating pad to the feet is not recommended for people with diabetes. This is because the heat can cause burns, especially in those with neuropathy who may not be able to feel how hot the pad is.

Choice C rationale

Rounding the corners of toenails with a nail file is not recommended as it can lead to ingrown toenails. Instead, toenails should be cut straight across to avoid this.

Choice D rationale

While it’s important to keep skin moisturized to prevent dryness and cracking, lotion should not be applied between the toes. This area can stay moist and warm, creating an ideal environment for fungal infections.

Choice A rationale

Loosening the screws while cleaning the pin sites is not recommended. The screws are tightened to a specific pressure to ensure the halo vest is secure and provides the necessary immobilization.

Choice B rationale

The nurse should also provide education regarding changing positions at least every 2 hours to reduce pressure injuries.

Choice C rationale

Halo-vests are managed and monitored during spinal outpatient clinics and can be removed during this clinic appointment.

Choice D rationale

The halo ring should never be used to lift or reposition the client because it is directly attached to the skull. Pulling on the ring could cause serious injury or dislocation.