A client who has a new diagnosis of type 2 diabetes mellitus is being taught about foot care by a nurse. Which of the following statements should the nurse include?

Correct Answer: C

Rationale: The correct answer is C. Trimming toenails straight across is essential for clients with diabetes to prevent the risk of ingrown toenails and injury. Using lotion on feet can be beneficial but should not be applied between the toes to avoid moisture buildup, which can lead to infections. Soaking feet in warm water can lead to dry skin, increasing the risk of cracks and other complications. Applying a heating pad to feet when they feel cold is not recommended for clients with diabetes due to impaired sensation, which can result in burns and other injuries.

Correct Answer: C

Rationale: In caring for a client with schizophrenia experiencing delusions, it is essential to focus on the client's feelings rather than directly addressing or challenging the delusions. By focusing on the client's emotions, the nurse can build trust and rapport without reinforcing the delusions. Choice A is incorrect because directly telling the client that their delusions are not real may lead to confrontation or mistrust. Choice B is incorrect as encouraging exploration of the delusions may further validate them. Choice D is incorrect because challenging the client's delusions can escalate the situation and damage the therapeutic relationship.

Correct Answer: C

Rationale: The correct answer is to use a picture board to facilitate communication. Aphasia can make it challenging for individuals to understand and use language. Using a picture board can help the client convey their needs and understand information more effectively. Speaking louder (A) may not be helpful as aphasia is not related to hearing loss. While speaking using simple sentences and gestures (B) can be beneficial, using a picture board (C) is a more concrete and visual method to support communication for individuals with aphasia. Having the client practice writing words down (D) may not be suitable if the client's expressive language skills are impaired due to aphasia.

Correct Answer: A

Rationale: In this scenario, the correct answer is option A) Blood urea nitrogen (BUN) 25 mg/dL. When a client is receiving gentamicin, it is crucial to monitor kidney function as this antibiotic can be nephrotoxic. An elevated BUN level indicates impaired kidney function, which can be an early sign of nephrotoxicity. Therefore, the nurse should report this finding to the provider promptly for further evaluation and possible adjustment of the medication regimen. Option B) Serum creatinine 1.5 mg/dL is also a marker of kidney function, but it is within the normal range. While an increase in creatinine may indicate kidney damage, it is not as sensitive as BUN for detecting early changes. Option C) Serum glucose 110 mg/dL is within the normal range and is not directly related to gentamicin therapy. Option D) White blood cell (WBC) count 5,000/mm3 is within the normal range and is not specifically indicative of gentamicin-related adverse effects. Educationally, understanding the importance of monitoring specific laboratory values when administering certain medications is crucial for nurses to ensure patient safety and early detection of potential complications. This rationale emphasizes the significance of vigilant assessment and prompt reporting of abnormal findings to healthcare providers.

Correct Answer: B

Rationale: The correct answer is to rotate injection sites within the same region to prevent tissue damage. By rotating sites, the client can prevent lipodystrophy, which is a condition characterized by the loss or change in body fat at the site of repeated injections. This practice also helps to ensure proper insulin absorption. Storing unopened vials of insulin in the refrigerator (Choice A) is correct, not in the freezer, as freezing can damage the insulin. Administering insulin at a 90-degree angle (Choice C) is more appropriate for subcutaneous injections, while a 45-degree angle is used for intramuscular injections. Massaging the injection site after administering insulin (Choice D) is not recommended as it can affect insulin absorption rates.