The nurse is performing a foot assessment for a client with diabetes. Which finding requires immediate intervention?
A small callus on the side of the foot.
Slight discoloration of the toenails.
An area of skin that is cracked and bleeding.
Mild swelling of the ankle.
The Correct Answer is C
An area of skin that is cracked and bleeding indicates a breakdown of the skin's integrity, which can lead to infection. Immediate intervention is needed to clean and protect the area.
Incorrect choices:
a. This choice is incorrect. A small callus may require intervention, but it does not necessarily require immediate attention unless it is causing discomfort or open sores.
b. This choice is incorrect. Slight discoloration of the toenails may be due to various factors and does not indicate an immediate need for intervention.
d. This choice is incorrect. Mild swelling of the ankle may require monitoring, but it does not necessarily indicate an immediate need for intervention unless it is accompanied by other concerning symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Clients with diabetes should be instructed to trim their toenails straight across to prevent ingrown toenails and potential foot infections.
Incorrect choices:
b. This choice is incorrect. Trimming toenails in a curved shape can increase the risk of ingrown toenails and should be avoided.
c. This choice is incorrect. Trimming toenails too short can lead to cuts, infections, and other foot problems.
d. This choice is incorrect. Trimming toenails at a 90-degree angle is not recommended and may lead to ingrown toenails.
Correct Answer is B
Explanation
Daily foot care is crucial to prevent foot complications and identify problems early, such as cuts, blisters, or changes in skin integrity, which can lead to serious complications in individuals with diabetes.
Incorrect choices:
a. This choice is incorrect. While daily foot care is important, its primary focus is on preventing foot complications, not weight loss or diabetes management.
c. This choice is incorrect. Foot care should be performed routinely, not just when numbness or tingling is experienced, to prevent complications.
d. This choice is incorrect. Waiting until a visible foot injury is noticed may lead to delayed intervention and increased risk of complications. Daily foot care is preventive in nature.
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