A nurse is collecting data on a client who has peripheral neuropathy. Which of the following findings should the nurse expect?

Increased ability to detect temperature

Burning sensation in feet

Loss of sensation to pressure

Hyperreflexia

Answer and Explanation

The Correct Answer is B

A.   Peripheral neuropathy typically results in a decreased ability to detect temperature changes due to nerve damage. Clients often experience reduced sensation or may not feel temperature variations accurately.
B.   This is a common symptom of peripheral neuropathy. Many clients report a burning, tingling, or "pins and needles" sensation in their feet. This phenomenon is often associated with nerve damage, especially in conditions like diabetes.
C.   Peripheral neuropathy can lead to diminished or altered sensation, including the inability to sense pressure accurately. Clients may not feel pressure on their feet, which increases the risk of injuries and ulcers.
D.   Hyperreflexia refers to increased reflex responses, which may occur with upper motor neuron lesions or central nervous system issues, not peripheral nerve damage. Peripheral neuropathy usually results in diminished reflexes or areflexia.

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Correct Answer is D

Explanation

A. This action is not appropriate as it could stimulate the gag reflex and lead to choking or aspiration. It does not contribute to effective oral care. Instead, gentle techniques using appropriate tools should be used to clean the mouth.
B. Holding the toothbrush at a 90° angle can be effective for brushing teeth as it allows for better access to the surfaces of the teeth. However, for an unconscious patient, this angle might not be practical or safe depending on the circumstances.
C. Vigorous brushing is not recommended, especially for an unconscious client. It could cause damage to the gums, lead to discomfort, or risk aspiration of fluids. Gentle brushing is advised to clean the teeth and gums without causing injury.
D. Turning the client to the side helps prevent aspiration of saliva or any fluids that may be in the mouth. It also provides better access for oral care and minimizes the risk of choking. This position is often recommended for unconscious patients to maintain their safety during oral care.

A. Objective B. Subjective C. Plan D. Assessment

Correct Answer is A

Explanation

A. The objective portion of the SOAP note includes measurable and observable data obtained through physical examination, assessments, and diagnostic tests. Vital signs (such as blood pressure, heart rate, respiratory rate, and temperature) are considered objective data.
B. The subjective section includes information reported by the client, such as their feelings, perceptions, and experiences. This can include complaints of pain or descriptions of symptoms but does not include measurable data like vital signs.
C. The plan section outlines the interventions, treatments, and actions to be taken based on the assessment findings. While it may reference vital signs in terms of monitoring or interventions related to them, it does not contain the actual recorded vital sign values.
D. The assessment section includes the nurse’s clinical judgment based on the subjective and objective data. It may summarize findings or indicate potential diagnoses but does not include the actual vital sign measurements.

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A nurse is collecting data on a client who has peripheral neuropathy. Which of the following findings should the nurse expect?

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