A nurse is caring for a client who has an acute exacerbation of chronic pain. Which of the following medications should the nurse anticipate administering for the client?

Rationale:

A. Keep the foot in plantar flexion: Maintaining the foot in plantar flexion increases the risk of developing foot drop by shortening the dorsiflexor muscles. This position does not support proper alignment or prevent contractures, making it counterproductive for prevention.

B. Elevate the client's feet on pillows: Elevating the feet may help reduce edema but does not prevent foot drop. It does not maintain proper dorsiflexion or support the ankle in a neutral position, so it is not effective for contracture prevention.

C. Brace the foot with an ankle-foot orthotic: An ankle-foot orthotic maintains the foot in a neutral position, preventing plantar flexion contractures and promoting proper alignment of the ankle. This intervention is highly effective for preventing foot drop in immobile clients by keeping the muscles and tendons stretched appropriately.

D. Perform passive range of motion of the ankle twice per day: Passive range of motion helps maintain joint mobility and circulation but alone may be insufficient to prevent foot drop. Consistent bracing or positioning is necessary to maintain neutral alignment when the client is not actively moving the ankle.

Rationale:

A. Confusion: Confusion is an early neurological manifestation of hypoglycemia caused by insufficient glucose supply to the brain. Clients may also experience irritability, shakiness, or difficulty concentrating, which are key indicators to assess for after insulin administration.

B. Acetone breath: Acetone or fruity breath odor is associated with diabetic ketoacidosis (DKA), a hyperglycemic emergency, not hypoglycemia. This occurs due to ketone buildup when insulin is deficient, which is opposite of low blood glucose.

C. Polydipsia: Excessive thirst is a symptom of hyperglycemia, not hypoglycemia. It occurs when elevated glucose levels cause osmotic diuresis, leading to dehydration and thirst, and is not expected shortly after insulin lispro administration.

D. Hot, dry skin: Hot, dry skin is typically associated with hyperglycemia or fever. In hypoglycemia, the client often exhibits cool, clammy skin due to sympathetic nervous system activation and sweating, making this finding inconsistent with low blood glucose.