A male client with diabetes mellitus (DM) is transferred from the hospital to a rehabilitation facility following treatment for a stroke with resulting right hemiplegia. The client reports his feet feel uncomfortably cool at night, preventing him from falling asleep. Which action should the nurse implement?

Use a bed cradle to hold the covers off feet.

Provide a warming pad (Aqua-pad or K-pad) to feet.

Place warm blankets next to the client’s feet.

Medicate the client with a prescribed sedative.

Answer and Explanation

The Correct Answer is B

Choice A reason: Using a bed cradle to hold the covers off feet is not a good option for a client with DM and right hemiplegia, because it can increase the risk of injury and infection to the feet. The client may have reduced sensation and circulation in the feet due to diabetic neuropathy and peripheral vascular disease, which can make the feet more prone to ulcers, gangrene, and amputation. The client should keep the feet covered and protected from pressure and trauma.

Choice B reason: Providing a warming pad (Aqua-pad or K-pad) to feet is the best option for a client with DM and right hemiplegia, because it can help improve the blood flow and comfort to the feet. The warming pad is a device that circulates warm water or air through a pad that is placed on the skin. The nurse should monitor the temperature and duration of the warming pad, and check the skin for signs of burns or blisters.

Choice C reason: Placing warm blankets next to the client’s feet is not a reliable option for a client with DM and right hemiplegia, because it may not provide enough warmth and may slip off during the night. The client may not be able to adjust the blankets due to the hemiplegia, which can affect the movement and strength of the right side of the body. The client may also have difficulty feeling the blankets due to the neuropathy.

Choice D reason: Medicating the client with a prescribed sedative is not a suitable option for a client with DM and right hemiplegia, because it does not address the underlying cause of the cool feet, and may have adverse effects on the client’s condition. The sedative may interact with the client’s other medications, such as insulin or oral hypoglycemics, and cause hypoglycemia, which can worsen the stroke recovery. The sedative may also cause respiratory depression, which can affect the oxygen delivery to the brain and the feet.

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Correct Answer is D

Explanation

Choice A reason: Clear, dark amber-colored urine is not a sign of improvement for a client with cirrhosis and hepatic failure. It may indicate dehydration, which can worsen the condition of the liver and kidneys. The client should be encouraged to drink enough fluids to maintain hydration and urine output.

Choice B reason: Improved level of consciousness is a positive sign for a client with cirrhosis and hepatic failure, but it is not directly related to the treatment plan of low sodium diet and albumin infusions. It may indicate a reduction in ammonia levels, which can cause hepatic encephalopathy, a condition that affects the brain function. The client should be monitored for signs of mental status changes, such as confusion, lethargy, or coma.

Choice C reason: Prothrombin time within normal limits is also a good sign for a client with cirrhosis and hepatic failure, but it is not the main goal of the treatment plan of low sodium diet and albumin infusions. It may indicate an improvement in the liver's ability to produce clotting factors, which can prevent bleeding complications. The client should be checked for signs of bleeding, such as bruising, petechiae, or hematemesis.

Choice D reason: Decreased abdominal girth is the best indicator of progress toward the desired effect of the treatment plan of low sodium diet and albumin infusions. It means that the client has reduced fluid retention and ascites, which are common complications of cirrhosis and hepatic failure. The client should be measured for abdominal girth daily, and weighed regularly, to monitor the fluid status.

A. Husky voice and complaints of hoarseness. B. Warm, soft, moist, salmon-colored skin. C. Visible swelling of the neck, with no pain. D. Central-type obesity, with thin extremities.

Correct Answer is D

Explanation

Choice A reason: A husky voice and complaints of hoarseness are not related to Cushing's syndrome, but may indicate a thyroid disorder or vocal cord damage.

Choice B reason: Warm, soft, moist, salmon-colored skin is not a characteristic of Cushing's syndrome, but may be seen in hyperthyroidism or infection.

Choice C reason: Visible swelling of the neck, with no pain, is not a sign of Cushing's syndrome, but may indicate a goiter or thyroid enlargement.

Choice D reason: Central-type obesity, with thin extremities, is a common feature of Cushing's syndrome, which is caused by excess cortisol production or exposure. Cortisol causes fat redistribution to the trunk, face, and back of the neck, while causing muscle wasting and weakness in the arms and legs.

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Naxlex Comprehensive Predictor Exams

An older client with cirrhosis of the liver and hepatic failure is placed on a low sodium diet and is receiving periodic albumin infusions. Which assessment finding indicates progress toward the desired effect of this treatment plan?

Correct Answer is D

Explanation

Which admission assessment findings should the nurse document related to a client who has been diagnosed with Cushing’s syndrome?

Correct Answer is D

Explanation

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