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 []

Explanation

Potential Condition: Anthrax

The client's flu-like symptoms followed by shortness of breath, cough, and chest pain align with potential inhalation anthrax. Furthermore, working in a government building and opening a suspicious package containing white powder suggests potential exposure to anthrax spores.
Actions to Take:

Place the client in isolation - Isolating the client helps prevent potential transmission of anthrax to others.
Apply oxygen via nasal cannula: The client's low oxygen saturation (88%) necessitates oxygen therapy to improve oxygen delivery to tissues.

Parameters to Monitor:

Arterial blood gases - Monitoring arterial blood gases helps assess the client's respiratory status and oxygenation levels, which may be compromised in anthrax-related respiratory distress.
Breath sounds - Monitoring breath sounds helps assess the effectiveness of respiratory interventions and detect any changes indicative of worsening respiratory status.

A. Increase IV fluids to 150 mL/hr B. Monitor for adverse reaction to antibiotics C. Repeat CD4+ T-cell count STAT D. Initiate airborne isolation E. Administer antiemetic

Correct Answer is ["A","B","E"]

Explanation

A. This intervention is likely to be ordered due to the patient's fever and elevated heart rate, which may suggest dehydration or the need for increased fluid intake to support hemodynamic stability and mitigate the effects of fever and potential dehydration from fever and nausea.
B. Given the diagnosis of Pneumocystis pneumonia, the patient will likely be on or start antibiotics specific to this infection, such as trimethoprim-sulfamethoxazole. Monitoring for adverse reactions is crucial, especially in a newly diagnosed HIV-positive patient who might be starting multiple new medications.
C. While it is important to monitor CD4 counts in HIV-positive patients to guide treatment decisions, repeating the CD4 count immediately might not be prioritized unless there are specific clinical changes that suggest a rapid decline in immune function. Given the recent test results showing a CD4 count of 443 cells/mm^3, immediate retesting might not be clinically justified unless guided by other symptoms or considerations not detailed here.
D. Pneumocystis pneumonia does not require airborne isolation as it is not typically contagious between people under normal circumstances. Instead, it arises as an opportunistic infection in individuals with weakened immune systems. Hence, this order would not be appropriate unless there were other infections suspected that require such precautions.
E. The patient reports severe nausea, which not only is distressing but can also prevent the patient from taking oral medications and maintain necessary nutrition. Administering an antiemetic can help manage this symptom effectively.

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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

Patient Data Exhibits Complete the diagram by dragging from the choices below to specify 1 potential condition the client is most likely experiencing, 2 actions the nurse would take to address that condition, and 2 parameters the nurse would monitor to assess the client's progress.

Correct Answer is []

Explanation

Patient Data Exhibits What order(s) should the nurse anticipate being prescribed after an update is reported to the healthcare providers? Select all that apply.

Correct Answer is ["A","B","E"]

Explanation

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