An older client is admitted after falling while walking. The left leg is externally rotated and shorter than the right leg, and the client is having severe pain and tingling in the left foot. The nurse is unable to palpate the left pedal pulses. Which action is most important for the nurse to implement?

Correct Answer: A

Rationale: In this scenario, the most important action for the nurse to implement is option A, using a doppler to assess bilateral pedal pulses. This is crucial in determining the vascular status of the affected leg, especially in a situation where a client presents with an externally rotated and shortened leg, severe pain, tingling, and absent pedal pulses. Without proper circulation, there is a risk of ischemia and potential long-term complications. Option B, administering pain medication, is not the most critical action at this stage. While managing pain is important, assessing vascular status takes precedence to ensure adequate blood flow to the affected limb. Option C, positioning the client's left leg in a neutral position, may offer some comfort but does not address the urgent need to assess circulation. Delaying vascular assessment can lead to further complications. Option D, immobilizing the left leg, is not appropriate without first assessing the vascular status. Immobilization may be necessary later for treatment but should not delay immediate assessment and intervention for vascular compromise. In an educational context, this scenario highlights the importance of prompt and systematic assessment in nursing practice, especially in emergencies involving potential vascular compromise. Nurses must prioritize actions based on the client's condition to provide safe and effective care. Understanding the rationale behind each option helps nurses develop critical thinking skills to make sound clinical judgments in similar situations.

Correct Answer: D

Rationale: In this scenario, the correct response is option D: Demonstrate the use of visual scanning during meals to the client and family. This is the most appropriate action because the client's difficulty with visual perception may be impacting her ability to see and recognize food on her plate, leading to decreased intake. By teaching the client and family how to use visual scanning techniques during meals, the nurse can help improve the client's ability to identify and consume food effectively. Option A: Encouraging the family to feed the client may undermine the client's independence and dignity. It is important to empower the client to feed themselves with appropriate assistance as needed. Option B: Suggesting that the family bring foods from home that the client enjoys does not address the underlying issue of visual perception difficulties. It is essential to address the root cause of the client's decreased food intake rather than simply offering different food options. Option C: Explaining that weight loss will be reversed after the acute phase of the stroke has ended does not provide immediate support or intervention for the client's current nutritional concerns. It is crucial to address the client's nutritional needs in the present moment to prevent further complications and promote recovery. In an educational context, understanding how to assess and address nutritional concerns in patients with neurological deficits, such as those following a CVA, is vital for pediatric cardiovascular nurses. Teaching effective strategies like visual scanning can significantly impact a patient's ability to maintain adequate nutrition and support their overall recovery and well-being.

Correct Answer: A

Rationale: The correct answer is A) Pain related to joint inflammation. In this case, the highest priority nursing diagnosis is addressing the client's pain related to joint inflammation. Pain management is crucial in providing comfort and improving the overall well-being of the client. Pain can significantly impact the client's quality of life, mobility, and ability to engage in daily activities. By effectively managing pain, the client can experience relief, improved mobility, and better adherence to treatment plans. Option B) Impaired physical mobility may be a concern for a client with RA, but in this scenario, addressing the pain is the priority as it directly impacts mobility. Option C) Risk for infection and Option D) Disturbed sleep pattern are not the immediate priorities compared to managing the client's pain and inflammation. In an educational context, understanding the principles of prioritization in nursing care is essential. By identifying the most urgent nursing diagnosis, nurses can effectively allocate resources and interventions to address the client's most critical needs first, ensuring optimal outcomes and patient-centered care.

Correct Answer: A

Rationale: In this scenario, the correct instruction for the nurse to emphasize during discharge teaching is option A) Check the insides and linings of all enclosed shoes before putting the shoes on. This instruction is crucial for a 70-year-old male client with type 2 diabetes mellitus (DM) who is hospitalized with an infected ulcer on his great right toe. Checking the insides and linings of shoes is important because it helps prevent pressure points, friction, and potential injury to the feet. Patients with diabetes, especially those with foot ulcers, are at higher risk for developing infections and complications due to reduced blood flow and nerve damage (neuropathy). Inspecting shoes ensures that no foreign objects are present that could cause further injury or infection. Option B is not the best choice because washing the feet with soap and water and applying a topical antibiotic ointment, although important for wound care, does not address preventive measures to avoid future foot injuries. Option C, trimming toenails weekly, may increase the risk of injury, especially for individuals with diabetes who may have impaired sensation or circulation in their feet. Option D, avoiding sandals or open-toed shoes, is not as critical as checking the insides of enclosed shoes. While open-toed shoes can expose the feet to potential injury, the primary focus should be on ensuring that the footwear worn provides adequate protection and support for the feet. In an educational context, emphasizing the importance of proper foot care and preventive measures is essential in managing diabetic foot complications. Educating patients on inspecting their shoes can help reduce the risk of ulcers and injuries, ultimately promoting better foot health and overall well-being for individuals with diabetes.

Correct Answer: D

Rationale: In the case of an adult client admitted with flank pain and diagnosed with acute pyelonephritis, the priority nursing action is to administer IV antibiotics as prescribed (Option D). This is because acute pyelonephritis is a bacterial infection of the kidneys that requires prompt antibiotic treatment to prevent complications such as sepsis or kidney damage. Administering antibiotics promptly is crucial to start combating the infection and prevent its progression. A) Auscultating for the presence of bowel sounds (Option A) is not the priority in this situation as the main concern is addressing the underlying infection in the kidneys. B) Monitoring hemoglobin and hematocrit (Option B) is important for assessing for anemia or blood loss, but it is not the priority in the immediate management of acute pyelonephritis. C) Encouraging turning and deep breathing (Option C) is a general nursing intervention to promote lung expansion and prevent respiratory complications but is not the priority action when dealing with a bacterial infection like pyelonephritis. In an educational context, it is essential for nursing students to understand the principles of prioritizing nursing actions based on the client's condition and needs. Understanding the pathophysiology of conditions like acute pyelonephritis and the rationale behind specific interventions helps students develop critical thinking skills and clinical judgment necessary for providing safe and effective patient care.