Nokea
All of the following are instructions for proper foot care to be given to a client with peripheral vascular disease caused by diabetes. Which one is not?
- A. Trim nails using a nail clipper
- B. Apply cornstarch to the foot
- C. Always check the temperature of the water before bathing
- D. Use canvas shoes
Correct Answer: A
Rationale: The correct answer is 'A', which says trim nails using a nail clipper. This is incorrect because patients with peripheral vascular disease, particularly those caused by diabetes, should not trim their nails themselves due to the risk of injury, infection, and poor wound healing. The other options, 'B', 'C', and 'D', are correct advice for diabetic foot care. Applying cornstarch can help keep the feet dry and prevent fungal infections. Checking the water temperature before bathing can prevent burns, as patients with peripheral vascular disease often have decreased sensation in their feet. Wearing canvas shoes can improve foot ventilation and reduce the risk of foot ulcers and infections.
You may also like to solve these questions
If it is determined that a child is being physically abused by a parent, what would be the most important goal for the nurse to establish with the family?
- A. The child and any siblings will reside in a secure environment
- B. The family will feel at ease in their relationship with the counselor
- C. The family will gain insight into their abusive behavior patterns
- D. The mother will learn to apply verbal discipline with her children
Correct Answer: A
Rationale: The primary objective when dealing with cases of child abuse is to ensure the safety of the child and any siblings. This means creating a secure environment free from harm, which is why choice 'A' is the correct answer. While choices 'B', 'C', and 'D' might be subsequent steps in a comprehensive plan to deal with the situation, they are not the immediate priority. Understanding abusive behavioral patterns or improving the relationship with the counselor will not directly lead to the child's safety. Likewise, teaching the mother to apply verbal discipline doesn't guarantee the child's safety if the abusive behavior continues. Therefore, these options are not the most important initial goal.
During which phase of the therapeutic relationship should the nurse inform the patient about the termination of therapy?
- A. Pre-orientation
- B. Orientation
- C. Working
- D. Termination
Correct Answer: D
Rationale: The correct answer is 'Termination'. This phase of the therapeutic relationship is when the nurse informs the patient about the conclusion of therapy. It is during this phase that the nurse and the patient review the goals and progress made and also discuss the upcoming termination. The other phases are not the appropriate times for discussing termination. 'Pre-orientation' is the phase before the nurse-patient relationship is established; 'Orientation' is when the nurse and patient get to know each other and set goals; and 'Working' is when these goals are pursued. Therefore, choices A, B, and C are incorrect.
Which food is a reliable source of B12 for a pregnant vegan client?
- A. Soybeans
- B. Algae
- C. Fortified soy milk
- D. Sea vegetables
Correct Answer: C
Rationale: Fortified soy milk is a reliable source of vitamin B12 for pregnant vegan clients as it is usually enriched with this vitamin. The other options, while nutritious, are not reliable sources of B12 for vegans. Soybeans may not provide enough B12, algae contains B12 analogs that the human body cannot utilize, and the B12 content in sea vegetables can fluctuate, potentially not providing the necessary daily intake.
Which of the following actions would be of highest priority with regards to the external shunt?
- A. Avoid taking blood pressure or blood sample from the arm with the shunt
- B. Instruct the patient not to exercise the arm with the shunt
- C. Heparinize the shunt daily
- D. Change the dressing of the shunt daily
Correct Answer: C
Rationale: Heparinizing the shunt daily (choice C) is the highest priority action as it prevents the formation of blood clots that can occlude the shunt, leading to potential complications such as thrombosis. Avoiding taking blood pressure or blood samples from the arm with the shunt (choice A) is also important, but secondary to heparinizing the shunt. Similarly, instructing the patient not to exercise the arm with the shunt (choice B) can help prevent unnecessary strain on the shunt, but it is not as critical as preventing clot formation. Changing the dressing of the shunt daily (choice D) is a standard nursing care practice to prevent infection, but again, it is not as critical as ensuring the shunt remains patent through daily heparinization.
What should be the next step in the nursing research process?
- A. Review related literature
- B. Seek permission from the hospital administrator
- C. Identify the research problem
- D. Develop methods for data collection
Correct Answer: D
Rationale: The correct answer is 'Develop methods for data collection' (Choice D). In the nursing research process, after the research problem has been identified, the next step would typically be to develop methods for how data will be collected. This is essential to effectively address the research problem. 'Review related literature' (Choice A), while an important step, usually occurs after the research problem has been identified and before methods for data collection are developed. 'Seek permission from the hospital administrator' (Choice B) might be necessary at some point in certain situations, but it is not the immediate next step in the research process. 'Identify the research problem' (Choice C) would typically come before developing methods for data collection. Therefore, according to the typical sequence of steps in the nursing research process, Choice D is correct.