The nurse is developing a teaching plan for a client with diabetes mellitus. A client with diabetes mellitus should:
- A. Use commercial preparations to remove
- B. Wash and inspect the feet daily
- C. Walk barefoot at least once each daily
- D. Cut the toenails by rounding edges
Correct Answer: B
Rationale: Clients with diabetes mellitus are at a higher risk for developing foot problems due to nerve damage and poor circulation. Washing and inspecting the feet daily is crucial in preventing and identifying any foot issues early. This practice helps in maintaining good foot hygiene, detecting any cuts, sores, or infections promptly, and preventing complications like diabetic foot ulcers. Walking barefoot is not recommended as it increases the risk of injury and infection, and cutting toenails by rounding edges can lead to ingrown toenails. Commercial preparations for foot care may contain ingredients that can be harmful to people with diabetes, so it is important to consult healthcare providers before using them.
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The patient is dangling at the bedside and states, "Oh, my stomach is tearing open." Which of the following actions should the nurse immediately take when dehiscence occurs?
- A. Have patient sit upright in a chair.
- B. Have patient lie down.
- C. Slow IV fluids.
- D. Obtain a sterile suture set.
Correct Answer: B
Rationale: When dehiscence, which is the separation of the layers of a surgical incision, occurs in a patient, it is important to have the patient lie down. This position will help decrease intra-abdominal pressure and reduce the risk of further complications. Having the patient sit upright in a chair can increase intra-abdominal pressure, worsening the dehiscence. Slowing IV fluids may be necessary to prevent fluid overload in certain situations, but it is not the immediate action required when dehiscence occurs. Obtain a sterile suture set may eventually be needed, but the priority in this situation is to stabilize the patient by having them lie down.
Nurse Melanie is teaching an adult class about the different types of hepatitis. Which statement does not pertain to hepatitis A?
- A. "Is caused by an RNA virus of the enterovirus family."
- B. "It spreads primarily by fecal-oral route, usually through the ingestion of infcetd food or liquids."
- C. "It may not be spread from sexual contact."
- D. "Type A hepatitis occurs worldwide, especially in areas with overcrowding and poor sanitation."
Correct Answer: A
Rationale: Statement A is incorrect because hepatitis A is not caused by an RNA virus of the enterovirus family. Instead, hepatitis A is caused by the hepatitis A virus (HAV), which belongs to the Picornaviridae family. Hepatitis A is primarily spread through the fecal-oral route, usually through the ingestion of contaminated food or water. Additionally, hepatitis A can be transmitted through close personal contact and sexual contact. While hepatitis A occurs worldwide, it is more prevalent in areas with poor sanitation and overcrowding.
Which of the following is disease process characterized by a chronic progressive inflammation of the sacroiliac and costovertebral joints and adjacent soft tissue?
- A. Rheumatoid arthritis
- B. Scoliosis
- C. Kyphosis
- D. Ankylosing spondylitis
Correct Answer: D
Rationale: Ankylosing spondylitis is a chronic inflammatory disease primarily affecting the sacroiliac joints and the spine. It leads to progressive inflammation of the sacroiliac and costovertebral joints, which can cause pain, stiffness, and eventually lead to fusion of the affected joints. This condition is also characterized by inflammation of other joints, tendons, and ligaments, as well as extra-articular manifestations such as uveitis and cardiac involvement. Ankylosing spondylitis is more common in young males and is associated with the presence of the HLA-B27 genetic marker. It is important to diagnose and manage ankylosing spondylitis early to help prevent complications and improve quality of life for affected individuals.
A patient complains of tingling in his fingers. He has positive Trousseau's and Chvostek's signs. He says that he feels depressed. Choose the most likely serum calcium (Ca ) value for this patient:
- A. 11mg/dl
- B. 7mg/dl
- C. 9mg/dl
- D. 5mg/dl
Correct Answer: A
Rationale: The patient's symptoms of tingling in the fingers, positive Trousseau's and Chvostek's signs, and feeling depressed are suggestive of hypocalcemia, which is commonly associated with low serum calcium levels. In this case, the most likely serum calcium value would be below the normal range, which is around 8.5-10.5 mg/dl. Among the given choices, an extremely low calcium value of 5mg/dl (Choice D) would be more consistent with severe hypocalcemia presenting with tetany and other neuromuscular symptoms rather than depression and mild symptoms. On the other hand, a high calcium level of 11mg/dl (Choice A) would indicate hypercalcemia, which can lead to neuropsychiatric symptoms like depression, as seen in this patient's presentation. Therefore, Choice A (11mg/dl) is the most likely serum calcium value for
To meet the emotional needs of a 10-year-old patient who is dying, the most appropriate nursing action is to:
- A. answer questions honestly and frankly.
- B. avoid interruptions by coordinating nursing actions.
- C. encourage the patient to write in a journal.
- D. provide opportunities for the patient to interact with children of the same age.
Correct Answer: A
Rationale: Answering questions honestly and frankly helps build trust and provides clarity for the child during this difficult time.