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. Document the absence of the radial pulse:

While it's important to document findings accurately, it's also crucial to ensure that blood pressure measurements are obtained correctly. If the radial pulse becomes unpalpable before reaching the expected systolic pressure, further action is needed to obtain an accurate measurement.

B. Release the manometer valve immediately:

Releasing the manometer valve immediately would lead to deflating the cuff and potentially missing the opportunity to obtain an accurate blood pressure measurement. This action is not appropriate at this stage.

C. Inflate blood pressure cuff to 120 mm Hg:

When the radial pulse becomes unpalpable during cuff inflation, it indicates that the cuff pressure is above the systolic pressure. To accurately determine the systolic pressure, the cuff should be inflated to a higher pressure (usually 20-30 mm Hg above the point where the radial pulse disappears) and then slowly deflated while palpating for the return of the radial pulse.

D. Record a palpable systolic pressure of 90 mm Hg:

If the radial pulse is no longer palpable at 90 mm Hg, this suggests that the true systolic pressure is higher than 90 mm Hg. Recording a palpable systolic pressure of 90 mm Hg without further action would likely underestimate the true systolic pressure.

A. Enter the occurrence after the 1400 notes and identify as "late entry". B. Request removal initiated by the Health Information Manager. C. Create an electronic correction after 1400 notes are officially unlocked. D. Make an electronic addendum following the 1400 documentation.

Correct Answer is D

Explanation

A. Enter the occurrence after the 1400 notes and identify as "late entry":

While entering the occurrence after the 1400 notes is an option, labeling it as a "late entry" may not provide sufficient clarity regarding the timing of the documentation. Using a "late entry" label could potentially lead to confusion or misinterpretation.

B. Request removal initiated by the Health Information Manager:

Requesting removal of the 1400 notes by the Health Information Manager is not necessary in this scenario. The focus should be on accurately documenting the missed occurrence rather than removing previously entered documentation.

C. Create an electronic correction after 1400 notes are officially unlocked:

Making an electronic correction implies that there was an error in the original documentation. Since the issue here is not correcting an error but rather adding missed documentation, creating a correction may not be appropriate.

D. Make an electronic addendum following the 1400 documentation:

An electronic addendum allows the nurse to add additional information to the chart without altering the original entry. This approach maintains the integrity of the original documentation while clearly indicating that the 0900 occurrence was added after the fact. It's important to ensure that the addendum clearly identifies the timing of the documentation to maintain accuracy and transparency in the medical record.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is obtaining a systolic blood pressure by palpation. While inflating the cuff, the radial pulse is no longer palpable at 90 mm Hg. Which action should the nurse take?

Correct Answer is C

Explanation

After completing daily charting at 1400, the nurse realizes that a 0900 occurrence was not entered. Which is the best way for the nurse to enter computer documentation of the 0900 occurrence?

Correct Answer is D

Explanation

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