Which is the best intervention of the nurse for a diabetic patient who has rough skin on the feet and thick, overgrown toenails?

Gently trim the patient’s toenails after soaking the feet in warm soapy water.

Use a pumice stone to smooth roughened areas of skin on the patient’s feet.

Liberally apply lotion to the patient's feet especially between the toes.

Obtain a consultation for a podiatrist to assess the feet and provide nail care.

Answer and Explanation

The Correct Answer is D

Choice A reason: This is an incorrect choice because gently trimming the patient’s toenails after soaking the feet in warm soapy water is not the best intervention of the nurse for a diabetic patient who has rough skin on the feet and thick, overgrown toenails. Trimming the toenails can be risky for the diabetic patient, as it can cause bleeding, infection, or injury to the nail bed or surrounding skin. The nurse should avoid cutting the toenails of the diabetic patient, unless instructed by a podiatrist.

Choice B reason: This is an incorrect choice because using a pumice stone to smooth roughened areas of skin on the patient’s feet is not the best intervention of the nurse for a diabetic patient who has rough skin on the feet and thick, overgrown toenails. A pumice stone is a porous rock that can be used to exfoliate the skin and remove dead cells. However, it can also damage the skin and cause abrasions, irritation, or infection. The nurse should be careful when using a pumice stone on the diabetic patient, and avoid rubbing too hard or too often.

Choice C reason: This is an incorrect choice because liberally applying lotion to the patient's feet especially between the toes is not the best intervention of the nurse for a diabetic patient who has rough skin on the feet and thick, overgrown toenails. Applying lotion to the feet can help to moisturize and soften the skin, but it can also create a moist environment that can promote fungal growth and infection. The nurse should apply lotion sparingly to the feet of the diabetic patient, and avoid applying it between the toes.

Choice D reason: This is the correct choice because obtaining a consultation for a podiatrist to assess the feet and provide nail care is the best intervention of the nurse for a diabetic patient who has rough skin on the feet and thick, overgrown toenails. A podiatrist is a specialist who can diagnose and treat foot problems, such as nail disorders, skin conditions, or infections. The podiatrist can safely and effectively trim the toenails of the diabetic patient, and provide education and advice on foot care and prevention of complications. The nurse should refer the diabetic patient to a podiatrist at least once a year, or more often if needed.

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Correct Answer is B

Explanation

Choice A reason: This is an incorrect choice because temperature, pulse, and blood pressure are not the most important vital signs for a patient who is experiencing shortness of breath. Temperature is not directly related to respiratory function, and pulse and blood pressure can be affected by other factors, such as anxiety or medication.

Choice B reason: This is the correct choice because pulse, respirations, and oxygen saturation are the most important vital signs for a patient who is experiencing shortness of breath. Pulse reflects the heart rate and rhythm, which can be altered by respiratory distress. Respirations reflect the rate and depth of breathing, which can indicate the severity of the condition. Oxygen saturation reflects the percentage of hemoglobin that is bound with oxygen, which can indicate the adequacy of oxygenation.

Choice C reason: This is an incorrect choice because temperature, pulse, and respirations are not the most important vital signs for a patient who is experiencing shortness of breath. Temperature is not directly related to respiratory function, and respirations alone do not provide enough information about the oxygenation status of the patient.

Choice D reason: This is an incorrect choice because respirations, blood pressure, and pain are not the most important vital signs for a patient who is experiencing shortness of breath. Blood pressure can be affected by other factors, such as anxiety or medication, and pain is a subjective symptom that can vary from person to person. Oxygen saturation is a more objective and reliable indicator of oxygenation than pain.

A. Health-seeking behaviors related to expressed desire for better sleep B. Impaired bed mobility related to presence of CPAP mask on face C. Risk for impaired skin integrity related to tight-fitting mask on face D. Risk for powerlessness related to inability to breathe regularly during sleep

Correct Answer is D

Explanation

Choice A reason: This is an incorrect choice because health-seeking behaviors related to expressed desire for better sleep is not the highest priority nursing diagnosis for a patient who is starting CPAP therapy for sleep apnea. Health-seeking behaviors are actions that a person takes to improve their health and well-being. However, this is not the most urgent or life-threatening problem for the patient, as it does not pose an immediate risk of harm or injury.

Choice B reason: This is an incorrect choice because impaired bed mobility related to presence of CPAP mask on face is not the highest priority nursing diagnosis for a patient who is starting CPAP therapy for sleep apnea. Impaired bed mobility is the limitation of the patient's ability to move in bed. However, this is not the most urgent or life-threatening problem for the patient, as it does not cause an immediate risk of harm or injury.

Choice C reason: This is an incorrect choice because risk for impaired skin integrity related to tight-fitting mask on face is not the highest priority nursing diagnosis for a patient who is starting CPAP therapy for sleep apnea. Risk for impaired skin integrity is the potential for the patient's skin to be damaged or broken. However, this is not the most urgent or life-threatening problem for the patient, as it does not cause an immediate risk of harm or injury.

Choice D reason: This is the correct choice because risk for powerlessness related to inability to breathe regularly during sleep is the highest priority nursing diagnosis for a patient who is starting CPAP therapy for sleep apnea. Risk for powerlessness is the potential for the patient to feel a loss of control or self-efficacy. This is the most urgent and life-threatening problem for the patient, as it can result in psychological distress, anxiety, depression, or hopelessness.

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Which is the best intervention of the nurse for a diabetic patient who has rough skin on the feet and thick, overgrown toenails?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which vital signs are most important for a patient who is experiencing shortness of breath?

Correct Answer is B

Explanation

Which is the highest priority nursing diagnosis for a patient who is starting CPAP therapy for sleep apnea?

Correct Answer is D

Explanation

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