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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. How many popsicles are available.
This information might be helpful for logistical purposes or to assess how much the child has consumed, but it's not directly relevant to ensuring the appropriateness of the popsicles for a clear liquid diet.
B. If the popsicles are completely frozen.
While it's important that popsicles are properly frozen to avoid potential choking hazards, this does not address whether the popsicles meet the dietary requirement of clear liquids.
C. The color and flavor of gelatin used.
While this might be of interest, the key concern is whether the popsicles contain any non-clear components like fruit or pulp.
D. Whether they contain pulp or fruit.
For a child who needs clear liquids, it is important to ensure that the popsicles do not contain any solids like fruit or pulp. Clear liquids are meant to be easily digestible and not irritate the stomach further. Popsicles with pulp or fruit can be too heavy and might not be appropriate in this situation.
Correct Answer is ["C","E"]
Explanation
A. Drink a mixture of warm water, whiskey, and honey at bedtime:
This suggestion is not appropriate as alcohol consumption close to bedtime can disrupt sleep patterns and exacerbate sleep problems. Additionally, alcohol can interact with medications and pose risks to health.
B. Ask the healthcare provider for a mild sedative for bedtime:
While medication may be prescribed for sleep disturbances in some cases, it should not be the first line of treatment, especially in older adults. Sedatives can have adverse effects and may lead to dependency if used long-term. Non-pharmacological interventions should be tried first.
C. Avoid drinking caffeinated beverages late in the day:
This is an appropriate suggestion. Caffeine is a stimulant that can interfere with sleep, so avoiding caffeinated beverages late in the day can help improve sleep quality.
D. Take an afternoon nap to make up for missed sleep:
While napping may be beneficial for some individuals, particularly if they are sleep deprived, it can worsen sleep difficulties in others, especially if taken late in the day. For individuals with insomnia or frequent nighttime awakenings, avoiding naps or limiting them to earlier in the day may be helpful.
E. Establish a regular time for going to bed and getting up:
This is an appropriate suggestion. Establishing a consistent sleep schedule helps regulate the body's internal clock and promotes better sleep quality. Going to bed and waking up at the same time each day, even on weekends, can help synchronize sleep-wake cycles and improve overall sleep patterns.
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