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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Defibrillation is the immediate treatment of choice for ventricular fibrillation to restore a normal heart rhythm. It delivers an electric shock to the heart, which can stop the abnormal rhythm and allow the heart to resume its normal rhythm.
B. External pacing is not effective for ventricular fibrillation as it requires an organized electrical activity to pace.
C. Atropine is used for bradycardia, not ventricular fibrillation.

D. Amiodarone is used to stabilize the heart rhythm after defibrillation but is not the immediate treatment for VF.

A. Begin with questions that are less sensitive in nature. B. Share personal values to put the client at ease. C. Get the most difficult questions over with first. D. Ask questions in a vague, non-specific format.

Correct Answer is A

Explanation

A.Beginning with less sensitive questions helps establish trust and rapport with the client, making it easier to discuss more difficult topics later. This approach can make the client feel more comfortable and less threatened, thereby improving the quality of the information gathered.

B.Sharing personal values can introduce bias and potentially influence the client's responses, making the interview less objective.

C.Starting with the most difficult questions can make the client feel anxious and defensive, reducing the likelihood of obtaining honest and thorough responses.

D.Asking vague, non-specific questions can lead to ambiguous answers and fail to provide the detailed information needed for a proper assessment.

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The nurse is assessing the feet of a client with type 1 diabetes mellitus. Which finding requires immediate intervention by the nurse?

Nursing Test Bank

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