Which assessment findings put the patient at high risk for development of vision problems? (Select all that apply)

Choice A reason: This is the correct choice because presence of pedal pulses and intact sensation is the most important bath time assessment of the diabetic patient. Pedal pulses are the pulses that can be felt on the top or side of the foot, and they indicate the blood flow to the lower extremities. Intact sensation is the ability to feel touch, pain, temperature, and vibration on the skin, and it indicates the nerve function of the lower extremities. Diabetic patients are at risk of developing peripheral vascular disease and peripheral neuropathy, which can impair the blood flow and nerve function of the lower extremities, and lead to ulcers, infections, or amputations. The nurse should assess the pedal pulses and intact sensation of the diabetic patient regularly, especially before and after bathing, to monitor for any signs of complications or deterioration.

Choice B reason: This is an incorrect choice because presence of fingernail clubbing is not the most important bath time assessment of the diabetic patient. Fingernail clubbing is a condition where the nails become curved and enlarged, and the nail bed becomes soft and spongy. It is a sign of chronic hypoxia or low oxygen levels in the blood, and it can be associated with various diseases such as lung cancer, cystic fibrosis, or congenital heart defects. However, it is not a common or specific complication of diabetes, and it does not pose an immediate risk of harm or injury to the diabetic patient.

Choice C reason: This is an incorrect choice because presence of abdominal rebound tenderness is not the most important bath time assessment of the diabetic patient. Abdominal rebound tenderness is a sign of peritoneal inflammation, which is the inflammation of the membrane that lines the abdominal cavity and organs. It is elicited by pressing and releasing the abdomen quickly, and it causes pain when the pressure is released. It can be caused by various conditions such as appendicitis, diverticulitis, or peritonitis. However, it is not a common or specific complication of diabetes, and it does not pose an immediate risk of harm or injury to the diabetic patient.

Choice D reason: This is an incorrect choice because presence of any petechiae or bruises is not the most important bath time assessment of the diabetic patient. Petechiae are small, red, or purple spots on the skin that are caused by bleeding under the skin. Bruises are larger, blue, or purple areas on the skin that are caused by bleeding under the skin. They can be caused by various factors such as trauma, infection, medication, or blood disorders. However, they are not a common or specific complication of diabetes, and they do not pose an immediate risk of harm or injury to the diabetic patient.

Choice A reason: This is an incorrect choice because the patient has a history of noncompliance with prescribed therapeutic regimens is not a reason why this nursing diagnosis is considered to be a collaborative problem. A collaborative problem is a potential or actual health problem that requires the intervention of multiple health care professionals from different disciplines to achieve optimal patient outcomes. The patient's history of noncompliance is not related to the nature of the problem or the type of intervention required.

Choice B reason: This is an incorrect choice because the patient must be closely monitored in an intensive care unit is not a reason why this nursing diagnosis is considered to be a collaborative problem. A collaborative problem is a potential or actual health problem that requires the intervention of multiple health care professionals from different disciplines to achieve optimal patient outcomes. The patient's need for close monitoring is not related to the nature of the problem or the type of intervention required.

Choice C reason: This is an incorrect choice because prevention of septic shock is not a measurable patient outcome is not a reason why this nursing diagnosis is considered to be a collaborative problem. A collaborative problem is a potential or actual health problem that requires the intervention of multiple health care professionals from different disciplines to achieve optimal patient outcomes. The measurability of the patient outcome is not related to the nature of the problem or the type of intervention required.

Choice D reason: This is the correct choice because both nursing and physician-prescribed interventions are required is a reason why this nursing diagnosis is considered to be a collaborative problem. A collaborative problem is a potential or actual health problem that requires the intervention of multiple health care professionals from different disciplines to achieve optimal patient outcomes. The problem of septic shock is a complex and life-threatening condition that involves multiple organ systems and requires both medical and nursing interventions to prevent, treat, and monitor the patient's status.