The nurse is assessing the feet of a client with type 1 diabetes mellitus. Which finding requires immediate intervention by the nurse?
Hard, painless nodule over metatarsophalangeal joint of first toe.
Erythema and edema at the base of the left great toe.
Decreased response to pain discrimination on dorsal surface of foot.
Painful corns and calluses over hammer toes on both feet.
The Correct Answer is B
A. A hard, painless nodule may indicate a deformity but is not an emergency.
B. Erythema and edema at the base of the left great toe could indicate an infection, such as cellulitis, which requires immediate intervention to prevent complications.
C. Decreased response to pain discrimination suggests neuropathy, which is concerning but not immediately life-threatening.
D. Painful corns and calluses are chronic issues that need management but are not urgent.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C"]
Explanation
A. Falls can lead to head injuries or subdural hematomas, which can cause confusion in older adults. It is important to assess for recent trauma as a possible cause of the confusion.
B. An elevated temperature can indicate an infection, such as a urinary tract infection (UTI) or pneumonia, which are common causes of acute confusion in older adults.
C. Pain with urination is a symptom of a UTI, which can lead to confusion, especially in elderly patients with Parkinson's disease.
D. While maintaining adequate nutrition is important, increasing protein intake does not directly address the sudden onset of confusion.
E. Although knowing allergies is important for general safety, reviewing them does not help identify the cause of a new onset of confusion that began a week ago. This would be more relevant if the client were about to start a new medication.
Correct Answer is B
Explanation
A. Providing condoms in health clinics is a preventive measure but does not directly indicate the effectiveness of the secondary prevention program.
B. Diagnosing at-risk clients early in the disease process indicates successful secondary prevention efforts, as early diagnosis allows for prompt treatment and prevention of further transmission.
C. While increasing HPV vaccine prescriptions is a positive outcome, it does not directly reflect the effectiveness of the program in preventing STIs.
D. Improved client knowledge is important but does not directly measure the program's effectiveness in preventing STIs.
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