During a foot assessment, the nurse observes an area of skin that is discolored, darkened, and slightly raised. The client reports that the area has been present for several weeks. What action should the nurse take?

Apply an antibiotic ointment to the area.

Document the findings as a normal skin variation.

Instruct the client to keep the area dry and clean.

Refer the client for further evaluation by a healthcare provider.

Answer and Explanation

The Correct Answer is D

An area of discolored, darkened, and slightly raised skin that has been present for several weeks may indicate a potential skin condition or complication that requires further evaluation and treatment by a healthcare provider.

Incorrect choices:

a. This choice is incorrect. Applying an antibiotic ointment without a proper diagnosis may not address the underlying issue.

b. This choice is incorrect. The described findings are not consistent with a normal skin variation and require further assessment.

c. This choice is incorrect. While keeping the area dry and clean is important, it may not be sufficient to address the underlying issue.

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Correct Answer is C

Explanation

Regular daily inspections of the feet for signs of infection are crucial in preventing complications related to diabetic foot ulcers. Increased redness, swelling, warmth, and foul odor may indicate infection and should be reported to a healthcare provider.

Incorrect choices:

a. This choice is incorrect. Using hot water can damage the delicate tissue of the ulcer and increase the risk of infection. Lukewarm water is recommended for cleansing.

b. This choice is incorrect. Keeping the ulcer uncovered can expose it to dirt, bacteria, and the risk of further injury. Proper dressing and wound coverage are essential for wound healing.

d. This choice is incorrect. Soaking the feet in Epsom salt water is not recommended for diabetic foot ulcers, as it can cause drying and may delay wound healing.

A. "I will use a mirror to inspect the soles of my feet." B. "I will only check my feet if I notice a problem or pain." C. "I will perform the foot assessment at the end of the day when my feet are most swollen." D. "I will press my feet against a hard surface to assess any changes in skin color."

Correct Answer is A

Explanation

Using a mirror to inspect the soles of the feet allows for a thorough assessment of hard-to-see areas and early detection of any abnormalities.

Incorrect choices:

b. This choice is incorrect. Regular daily foot assessments are recommended to detect any issues early and prevent complications.

c. This choice is incorrect. Performing the foot assessment when feet are most swollen may make it more difficult to identify abnormalities.

d. This choice is incorrect. Pressing feet against a hard surface is not a standard technique for assessing foot health.

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During a foot assessment, the nurse observes an area of skin that is discolored, darkened, and slightly raised. The client reports that the area has been present for several weeks. What action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is providing education to a client with a diabetic foot ulcer about wound care and infection prevention. Which statement by the client indicates effective understanding of wound management?

Correct Answer is C

Explanation

The nurse is instructing a client with diabetes on how to perform a self-foot assessment. Which statement by the client indicates effective understanding of the assessment technique?

Correct Answer is A

Explanation

The nurse is providing education to a client with diabetes about moisturizing the feet. Which statement by the client indicates understanding of proper moisturizing techniques?

The nurse is assessing a client's feet for signs of infection as part of diabetic foot care. Which finding suggests a possible infection?

The nurse is assessing a client's feet as part of diabetic foot care. Which finding requires further assessment and intervention?

The nurse is educating a client with a diabetic foot ulcer about proper wound dressing. Which statement by the client indicates understanding of wound management?

The nurse is assessing a client's foot as part of diabetic foot care. Which finding requires immediate intervention?

The nurse is teaching a client with diabetes about foot care. Which statement by the client indicates a need for further education?

The nurse is educating a client with diabetes about preventing injuries to the feet. Which activity should the client avoid?

The nurse is teaching a client with diabetes about how to trim their toenails. Which instruction should the nurse provide?