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?

Risk for infection.

Impaired physical mobility.

Risk for impaired skin integrity.

Self care deficit.

Answer and Explanation

The Correct Answer is C

A. Risk for infection:

Neuropathy can compromise the ability to detect injuries or wounds on the feet. Consequently, there's a risk of wounds going unnoticed, becoming infected, and leading to serious complications. While preventing infection is important, the primary concern in this scenario is preventing the occurrence of wounds or skin breakdown in the first place.

B. Impaired physical mobility:

Impaired physical mobility may be a concern for clients with neuropathy, especially if it affects their ability to walk or perform activities of daily living. However, in this scenario, the client is reporting increasing numbness and tingling in the lower extremities, indicating a sensory issue rather than a motor one. Therefore, while physical mobility is important, it may not be the immediate priority for promoting foot care in this case.

C. Risk for impaired skin integrity:

This option addresses the potential risk of skin breakdown or damage due to decreased sensation in the lower extremities, which is characteristic of neuropathy. With increasing numbness and tingling, there's a higher risk that the client may not be able to perceive injuries or pressure points, leading to skin damage or ulceration. Preventing skin integrity issues is crucial to avoid complications such as infections or wounds.

D. Self-care deficit:

Neuropathy can indeed impact a person's ability to perform self-care activities, including foot care. However, the priority in this scenario is to prevent complications related to neuropathy, such as skin integrity issues, rather than addressing deficits in self-care abilities. While self-care education and support may be necessary in the long term, immediate intervention to prevent skin breakdown takes precedence.

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Correct Answer is C

Explanation

A. Turn the head to the right and left:

Turning the head involves rotation of the cervical spine, which primarily consists of pivot joints rather than hinge joints. This action is more relevant to the movement of pivot joints.

B. Extend the arm at the side and rotate in circles:

Extending the arm and rotating it in circles primarily involves the movement of ball-and-socket joints, such as the shoulder joint, rather than hinge joints.

C. Bend the arm by flexing the ulna to the humerus:

This action involves bending the arm at the elbow joint by flexing the ulna (forearm bone) towards the humerus (upper arm bone). The elbow joint is a hinge joint, allowing primarily flexion and extension movements.

D. Tilt the pelvis forwards and backwards:

Tilting the pelvis forwards and backwards primarily involves the movement of ball-and-socket joints in the hip area, rather than hinge joints.

A. Positive external places. B. Emotional reflection. C. Motivational phrases. D. Tranquil sounds.

Correct Answer is A

Explanation

A. Positive external places:

Guided imagery typically involves directing the client to visualize calming and peaceful external environments, such as a beach, forest, or other positive, serene places. This technique helps divert the client's attention away from pain and promotes relaxation.

B. Emotional reflection:

Emotional reflection may be part of the guided imagery process, especially if it helps the client process and cope with their emotions related to chronic pain. However, the primary focus of guided imagery is typically on visualization techniques rather than emotional reflection alone.

C. Motivational phrases:

Motivational phrases can be helpful in some relaxation techniques, but in guided imagery for chronic pain management, the emphasis is usually on visualizing soothing images or scenarios rather than repeating motivational phrases.

D. Tranquil sounds:

Tranquil sounds may be part of a relaxation strategy, but guided imagery specifically involves visualizing calming scenes, not just focusing on sounds.

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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?

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