A nurse is providing teaching about foot care to a client who has diabetes mellitus. Which of the following instructions should the nurse include? (Select all that apply)
"Alternate the shoes you wear each day."
"Apply synthetic fabric socks."
"Wear open-toe shoes"
"Wash your feet daily with warm water and soap”
"Soak your feet for 1 hour each day."
Correct Answer : A,B,D
Rationale:
A. "Alternate the shoes you wear each day.": Rotating shoes helps prevent pressure points and reduces the risk of skin breakdown or foot ulcers, which is important for clients with diabetes who have impaired circulation and sensation.
B. "Apply synthetic fabric socks.": Synthetic or moisture-wicking socks help keep feet dry and prevent fungal infections, a common concern in clients with diabetes. Cotton or synthetic blends are preferred over thick wool or socks that retain moisture.
C. "Wear open-toe shoes": Open-toe shoes increase the risk of injury, infection, and trauma, which can lead to serious complications in diabetic clients. Closed, well-fitting shoes provide protection and support.
D. "Wash your feet daily with warm water and soap": Daily washing and gentle drying of the feet helps maintain hygiene, prevents infection, and allows early detection of cuts, cracks, or sores. Warm, not hot, water prevents burns in clients with neuropathy.
E. "Soak your feet for 1 hour each day.": Prolonged soaking can cause skin maceration, increasing the risk of infection and breakdown. Soaking is generally discouraged for clients with diabetes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["2.5"]
Explanation
Calculation:
- Identify the ordered dose and available concentration
Ordered Dose: 20 mg
Available Concentration: 40 mg/5 mL
- Calculate the volume to administer
Volume to administer = (Ordered Dose ÷ Concentration) × Volume of Concentration
Volume to administer = (20 ÷ 40) × 5
Volume to administer = 0.5 × 5
Volume to administer = 2.5 mL
Correct Answer is C
Explanation
Rationale:
A. "Can you tune out the voices by listening to music?": This question focuses on coping strategies, which is important, but it is not the immediate priority. The nurse must first assess the content of the hallucinations to determine potential risk.
B. "Are you also seeing unusual persons or things?": Assessing for visual hallucinations is useful, but the client is currently experiencing auditory command hallucinations. Immediate focus should be on the commands to ensure safety.
C. "What are the voices telling you to do?": Determining the content of the voices is the priority because command hallucinations may instruct the client to harm themselves or others. Assessing risk and ensuring safety comes before exploring coping or additional symptoms.
D. "Do the voices cause you to feel anxious?": Assessing emotional response is relevant, but it is secondary to understanding whether the hallucinations pose a safety risk to the client or others.
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