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: 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.

A. Isolate the client from other clients, family, and healthcare workers not wearing proper PPE. B. Report the COVID-19 result to the local health department according to CDC guidelines. C. Teach the client to wear a mask, hand wash, and social distance to prevent spreading the virus. D. Explain to the client to inform others that they may have been potentially exposed in the last 14 days.

Correct Answer is A

Explanation

Choice A reason: Isolating the client from other clients, family, and healthcare workers not wearing proper PPE is the most important action that the nurse should take, because it can prevent the transmission of COVID-19, which is a highly contagious respiratory disease caused by a novel coronavirus. The client has symptoms that are consistent with COVID-19, such as conjunctivitis, loss of taste and smell, and recent travel history, and the nasal swab test can confirm the diagnosis. The nurse should follow the infection control precautions, such as wearing a mask, gloves, gown, and eye protection, and place the client in a private room with negative pressure ventilation, if available.

Choice B reason: Reporting the COVID-19 result to the local health department according to CDC guidelines is an important action that the nurse should take, but it is not the most important one. Reporting the COVID-19 result can help the public health authorities to monitor the epidemiology, track the contacts, and implement the interventions to control the outbreak. However, reporting the result can only be done after the test is completed and confirmed, which may take some time. The nurse should prioritize the immediate isolation of the client to prevent the spread of the virus.

Choice C reason: Teaching the client to wear a mask, hand wash, and social distance to prevent spreading the virus is an important action that the nurse should take, but it is not the most important one. Teaching the client to wear a mask, hand wash, and social distance can help the client to protect themselves and others from COVID-19, which can be transmitted through respiratory droplets, contact, and aerosols. However, teaching the client these measures can only be effective if the client follows them and adheres to the isolation guidelines. The nurse should first isolate the client and then provide the education.

Choice D reason: Explaining to the client to inform others that they may have been potentially exposed in the last 14 days is an important action that the nurse should take, but it is not the most important one. Explaining to the client to inform others that they may have been potentially exposed in the last 14 days can help the client to notify their close contacts, such as family, friends, co-workers, and travel companions, who may have been at risk of COVID-19 infection. However, explaining to the client this information can only be useful if the client cooperates and remembers their contacts. The nurse should first isolate the client and then assist the client with the contact tracing.

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Naxlex Comprehensive Predictor Exams

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

Two weeks after returning home from traveling, a client presents to the clinic with conjunctivitis and describes a recent loss in the ability to taste and smell. The nurse obtains a nasal swab to test for COVID-19. Which action is most important for the nurse to take?

Correct Answer is A

Explanation

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