A nurse is teaching a client who has diabetic neuropathy about foot care.
Which of the following instructions should the nurse include?
Apply lotion between the toes.
Wear open-toed shoes.
Avoid walking barefoot.
Wash feet in hot water.
The Correct Answer is C
Choice A rationale:
"Apply lotion between the toes.”. Applying lotion between the toes is not a recommended practice for individuals with diabetic neuropathy. The rationale for this is that excess moisture between the toes can create an environment conducive to fungal infections, which individuals with diabetes are more susceptible to due to compromised immune function and poor circulation.
Choice B rationale:
"Wear open-toed shoes.”. Wearing open-toed shoes is generally not recommended for individuals with diabetic neuropathy. Open-toed shoes expose the feet to potential injury and do not provide adequate protection. It's essential to wear closed-toed, well-fitting shoes to prevent foot injuries and complications.
Choice C rationale:
"Avoid walking barefoot.”. The correct answer, "Avoid walking barefoot," is a crucial instruction for individuals with diabetic neuropathy. Walking barefoot increases the risk of injury, as patients with neuropathy may not feel pain or discomfort from small cuts or injuries to their feet. It is essential to protect the feet by wearing shoes or slippers to minimize the risk of wounds and infections.
Choice D rationale:
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Correct Answer is A
Explanation
Choice A rationale:
The client who is unresponsive to verbal commands and changes position occasionally is at the highest risk for developing a pressure injury. Pressure injuries, also known as pressure ulcers or bedsores, are more likely to occur in clients who cannot independently reposition themselves. Unresponsive clients are unable to sense discomfort and adjust their positions, which makes them particularly vulnerable to pressure injuries. Changing position occasionally may not be sufficient to prevent these injuries in such clients. Pressure injuries are a result of prolonged pressure on a particular area, causing damage to the skin and underlying tissues due to reduced blood flow. Clients who are unresponsive need more vigilant monitoring and frequent repositioning to prevent pressure injuries.
Choice B rationale:
The client who is alert and responsive and eats 25% of each meal is not at the highest risk for developing a pressure injury. While this client may have some nutritional concerns, the primary risk factor for pressure injuries is immobility or the inability to change position independently. The ability to eat some of each meal indicates at least some level of mobility and participation in activities of daily living, which can help reduce the risk of pressure injuries.
Choice C rationale:
The client who is receiving enteral feeding and can change position independently is not at the highest risk for developing a pressure injury. Enteral feeding provides adequate nutrition, and the ability to change position independently reduces the risk of pressure injuries. Changing positions helps distribute pressure and prevents localized areas of prolonged pressure that can lead to tissue damage.
Choice D rationale:
The client who makes frequent slight changes in position and walks occasionally is also not at the highest risk for developing a pressure injury. Walking and frequent position changes help in preventing pressure injuries. The risk is lower for clients who can independently make slight changes in position and engage in ambulation. These activities promote blood flow and relieve pressure on specific areas of the body.
Correct Answer is A
Explanation
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