A nurse is collecting data from a client who has diabetes mellitus.
The nurse should ask which of the following to determine the client's ability to provide foot self-hygiene?

Do you have any problems taking care of your feet?

Do you go barefoot at home?

Have you noticed any problems with foot swelling?

Have you had a problem with ingrown toenails?

Answer and Explanation

The Correct Answer is A

Choice A rationale

Asking if there are any problems taking care of feet directly assesses the client’s ability to perform foot self-hygiene. It opens up discussion about specific difficulties the client may face, such as flexibility, vision, or dexterity issues.

Choice B rationale

Asking if the client goes barefoot at home is related to foot safety but does not directly assess their ability to perform foot self-hygiene. It's important for preventing injuries and infections, especially in clients with diabetes.

Choice C rationale

Inquiring about foot swelling helps identify potential complications related to diabetes but does not address the client's ability to perform foot self-care.

Choice D rationale

Asking about problems with ingrown toenails is specific to a common issue in diabetic foot care but does not provide a comprehensive assessment of the client’s ability to maintain foot hygiene.

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Correct Answer is A

Explanation

Choice A rationale

Guided imagery involves the use of mental visualization to relieve stress and manage pain. By thinking about a peaceful setting, such as the client’s grandfather's farm, they can divert attention from the pain and enter a state of relaxation. This technique helps reduce pain perception by engaging the mind in positive, soothing imagery, which can lead to decreased stress and muscle tension.

Choice B rationale

Listening to music is a distraction technique rather than guided imagery. While it can help take the mind off pain, it does not involve the mental visualization process that is central to guided imagery. Music can help by shifting attention away from pain and providing a calming effect through auditory stimulation.

Choice C rationale

Focused breathing is a relaxation technique that can help manage pain through controlled breathing patterns. It helps reduce anxiety and physical tension by focusing on slow, deep breaths. However, it does not involve the imaginative visualization that characterizes guided imagery.

Choice D rationale

Noticing the sensation of muscle tension is part of body awareness techniques, which involve paying attention to and understanding bodily sensations. While this can help in managing pain by addressing muscle tension, it is different from the mental visualization process of guided imagery.

A. Respiratory rate 10/min B. Pulse oximetry 88% on room air C. Blood pressure 99/46 mm Hg D. Morphine 10 mg administered subcutaneously

Correct Answer is ["A","B","D"]

Explanation

Choice A rationale: The client’s respiratory rate of 10/min is below the normal range (12-20 breaths per minute). This suggests respiratory depression, which can be caused by opioid medications like morphine.

Choice B rationale: The client’s pulse oximetry reading of 88% on room air is lower than the normal range (95%-100%). This indicates hypoxemia, which may be due to respiratory depression from the morphine.

Choice C rationale: Although the blood pressure of 99/46 mm Hg is low, it might be acceptable for this client postoperatively. However, it does not require immediate intervention compared to the other choices.

Choice D rationale: The administration of morphine 10 mg subcutaneously needs further action because the client is showing signs of opioid overdose (e.g., respiratory depression, hypoxemia). This necessitates reassessment and potential adjustment of the medication dosage or frequency.

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A nurse is collecting data from a client who has diabetes mellitus.The nurse should ask which of the following to determine the client's ability to provide foot self-hygiene?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client about using guided imagery to manage chronic pain.Which of the following statements by the client indicates an understanding of this technique?

Correct Answer is A

Explanation

Correct Answer is ["A","B","D"]

Explanation

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A nurse is collecting data from a client who has diabetes mellitus.
The nurse should ask which of the following to determine the client's ability to provide foot self-hygiene?