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 B

Explanation

A. While monitoring urinary output is important, it is not the most critical assessment in this context.
B. Monitoring serum electrolytes is crucial because the large amount of fecal liquid output from the ileostomy can lead to significant electrolyte imbalances.
C. Peristomal skin integrity is important but is secondary to the immediate risk of electrolyte imbalances.
D. Skin turgor is important for assessing hydration status, but monitoring electrolytes is more directly related to the immediate postoperative care.

A. A peanut butter sandwich with soda and cookies. B. A salad with three kinds of lettuce and fruit. C. A tuna fish sandwich with chips and ice cream. D. Vegetable soup, crackers, and milk.

Correct Answer is C

Explanation

A. Peanut butter sandwich with soda and cookies is not a high-protein choice and contains excessive sugar and empty calories.
B. Salad with lettuce and fruit may not provide sufficient protein for wound healing.

C. A tuna fish sandwich is high in protein, which aligns with the goal of promoting wound healing.
D. Vegetable soup, crackers, and milk lack adequate protein content compared to a tuna fish sandwich.

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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?

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Naxlex Comprehensive Predictor Exams

Assessment findings for a client following a colectomy for familial polyposis include an ileostomy bag that contains a large amount of fecal liquid and an IV infusion of dextrose 5% in lactated Ringer's infusing at a rate of 100 mL/hour. Which assessment is most

Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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