A client with an arterial ischemic leg ulcer is being discharged from the hospital. Which instruction is most important for the nurse to include in this client's discharge teaching plan?
Trim toenails straight across.
Inspect feet daily for skin breakdown.
Keep legs elevated as much as possible.
Wear shoes and socks while awake.
The Correct Answer is B
Choice A reason: Trimming toenails straight across is a general foot care recommendation but is not the most critical for preventing complications from an arterial ischemic leg ulcer.
Choice B reason: This is the correct choice. Daily inspection of the feet for skin breakdown is crucial for early detection and prevention of complications associated with arterial ischemic leg ulcers.
Choice C reason: Keeping legs elevated can help reduce swelling but is not as critical as daily foot inspection for preventing ulcer-related complications.
Choice D reason: Wearing shoes and socks is important for protecting the feet but does not directly prevent complications from an arterial ischemic leg ulcer.
 
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Correct Answer is D
Explanation
Choice A reason: Asking the client to choose the medication is not appropriate as the nurse should use clinical judgment to select the medication based on effectiveness and onset of action.
Choice B reason: Documentation is important but should not precede the administration of pain relief.
Choice C reason: Comparing the pain scale rating with prescribed dosing is part of pain management, but the immediate concern is to relieve the pain as quickly as possible.
Choice D reason: This is the correct choice. The nurse should determine which medication will provide the quickest relief from pain, which is the client's immediate need.
Correct Answer is A
Explanation
Choice A reason: Asymmetrical gluteal folds may indicate DDH due to uneven positioning of the hips.
Choice B reason: A positive Babinski test is normal in infants and is not specifically associated with DDH.
Choice C reason: A one-sided limp is not observable in newborns, as they are not yet walking.
Choice D reason: A positive Kernig sign is indicative of meningitis, not DDH, and is not relevant to the assessment of hip development.
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