An older adult client, who is insulin-dependent, arrives at the diabetic clinic with concerns of thick, crusty, and long toenails that are piercing the adjacent toes. Which action should the nurse take?

Cut the nails straight across, then soak the feet for 10 minutes in an antibiotic solution.

Check the client’s feet for cuts or injury, then refer to a foot specialist for nail trimming.

Soak the feet in warm water for 5 minutes, then cut the nails straight across.

Advise the client to soften the nails with lotion prior to cutting them.

Answer and Explanation

The Correct Answer is B

Choice A reason: Cutting nails and soaking in antibiotic solution risks infection in insulin-dependent diabetes, where neuropathy impairs sensation and healing. Thick nails may be fungal, needing specialist care. Checking for injuries and referring to a podiatrist ensures safe management, preventing ulcers in high-risk diabetic feet.

Choice B reason: Checking for cuts assesses diabetic foot risk, as neuropathy and poor glycemic control impair healing. Thick nails piercing toes require podiatrist trimming to prevent trauma or infection. Referral ensures expert care, addressing pathophysiological risks of neuropathy and vascular impairment, preventing serious complications like ulcers.

Choice C reason: Soaking and cutting nails is risky in diabetes, as neuropathy increases injury risk, and warm water may introduce infection in unnoticed wounds. Fungal nails need specialist care. Referral to a podiatrist ensures safe trimming, preventing infection in compromised feet, making this action unsafe.

Choice D reason: Advising lotion to soften nails does not mitigate injury risk from trimming thick nails in diabetes. Neuropathy and poor healing increase infection risk from errors. Specialist referral ensures safe nail management, preventing trauma or ulceration, critical in diabetic foot care due to vascular deficits.

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Correct Answer is C

Explanation

Choice A reason: Imbalanced nutrition is unrelated to 150 mL residual urine, which indicates incomplete bladder emptying, often from detrusor dysfunction or obstruction. Nutrition affects overall health but does not cause retention. Residual urine increases infection risk due to stasis, making nutrition an irrelevant nursing problem for this urinary issue.

Choice B reason: Deficient fluid volume suggests dehydration, reducing urine output, not causing high residual volumes. Residual urine (150 mL) indicates retention from impaired bladder emptying, not fluid deficit. Hydration prevents stasis, but infection risk from retained urine is more immediate, as bacteria proliferate in stagnant urine.

Choice C reason: Residual urine of 150 mL signifies incomplete bladder emptying, often from obstruction or neurogenic bladder, leading to urinary stasis. This fosters bacterial growth, increasing urinary tract infection (UTI) risk. Including “risk for infection” addresses this pathophysiological concern, guiding interventions like catheterization to reduce infection likelihood.

Choice D reason: Urinary incontinence involves involuntary leakage, not retention, where the bladder fails to empty, as seen with 150 mL residual urine. Retention results from outflow obstruction or weak detrusor, distinct from incontinence’s loss of control, making this nursing problem inappropriate for the client’s condition.

A. Remember exercise will not affect blood glucose levels. B. Follow the individualized meal plan and avoid high fat diets. C. Soak feet daily in hot water no longer than 10 minutes. D. Keep any wounds covered with an antibiotic ointment.

Correct Answer is B

Explanation

Choice A reason: Exercise lowers blood glucose in type 2 diabetes by enhancing insulin sensitivity and glucose uptake via GLUT4 transporters in muscles. This statement is incorrect, as physical activity is vital for glycemic control, reducing hyperglycemia and cardiovascular risks. Proper understanding involves recognizing exercise’s role in metabolic management, not denying its impact.

Choice B reason: Following a tailored meal plan and avoiding high-fat diets is correct, as it regulates blood glucose and lipids in type 2 diabetes. Balanced carbohydrates and low saturated fats prevent insulin resistance and atherosclerosis. This reflects understanding of dietary management’s role in glycemic control, reducing complications like neuropathy or cardiovascular disease.

Choice C reason: Soaking feet in hot water is dangerous in diabetes due to neuropathy, which reduces sensation and increases burn risk. Hot water also dries skin, raising infection risk. Proper foot care involves daily inspection and avoiding extreme temperatures, making this statement incorrect and harmful for effective diabetes management.

Choice D reason: Covering wounds with antibiotic ointment without medical evaluation is risky, as diabetes impairs wound healing due to hyperglycemia and immune dysfunction. Proper care involves cleaning, monitoring, and consulting providers to prevent infections. This statement shows incomplete understanding, as it overlooks the need for professional wound management.

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An older adult client, who is insulin-dependent, arrives at the diabetic clinic with concerns of thick, crusty, and long toenails that are piercing the adjacent toes. Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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