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. A respiratory rate of 35 breaths/minute can be normal for a 2-year-old, so it is not necessarily indicative of distress by itself.

B.Flaring of the nares is a sign of increased work of breathing and is an indication of respiratory distress, as the child is using accessory muscles to breathe.

C.Diaphragmatic respirations are typical for young children and not indicative of distress unless other signs are present.

D.Bilateral bronchial breath sounds do not necessarily indicate respiratory distress and could be normal depending on the context.

A. Viral meningitis whose temperature changed from 101° F (38.3°C) to 102° F (38.9°C) B. Myxedema coma whose blood pressure changed from 80/50 mm Hg to 70/40 mm Hg. C. Subdural hematoma whose blood pressure changed from 150/80 mm Hg to 170/60 mm Hg. D. Diabetic ketoacidosis whose Glasgow Coma Scale score changed from 10 to 7.

Correct Answer is A

Explanation

A. The client with viral meningitis and a slight increase in temperature can be managed by a PN, as this change in status is less acute and requires standard nursing care and monitoring.

B. The client with myxedema coma experiencing a significant drop in blood pressure requires more complex and immediate intervention by an RN due to the critical nature of the condition.
C. The client with a subdural hematoma and a significant change in blood pressure needs close monitoring and potential interventions by an RN, given the risk of increased intracranial pressure.
D. The client with diabetic ketoacidosis and a decreased Glasgow Coma Scale score is in a critical state requiring close monitoring and management by an RN.

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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

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Explanation

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Correct Answer is A

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