While assessing a client with type 2 diabetes mellitus (DM), the nurse observes an absence of hair growth on the client's lower legs. Which assessment provides further data to support this finding?

Appearance of the skin on the client's legs.

Altered posture and balance during ambulation.

Presence of bilateral femoral pulses.

Signs of old and new ecchymosis.

Answer and Explanation

The Correct Answer is A

A.   The absence of hair growth on the lower legs is a potential sign of peripheral neuropathy, a common complication of diabetes. Assessing the skin for other signs of neuropathy, such as dryness, cracking, or calluses, would provide further evidence to support this diagnosis.
B.   While this might indicate neuropathy, it's not as direct a correlation as the skin appearance.
C.   Assessing pulses helps to evaluate peripheral circulation, but it doesn't directly address the issue of hair loss, which is more related to nerve damage.
D.   Ecchymosis can indicate a bleeding disorder or trauma, not necessarily neuropathy.

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Correct Answer is A

Explanation

A. The client's symptoms of headache, blurred vision, vertigo, and nausea, even without abnormal vital signs, are suggestive of potential neurological complications from a head injury, such as increased intracranial pressure (ICP). This requires immediate attention and evaluation.
B. While the client is experiencing discomfort, it is secondary to the potential neurological issue.
C. The client's nutritional status is a concern, but it is not the priority at this time, given the potential neurological implications of the client's symptoms.
D. While the client's anxiety is understandable, it is not the primary concern given the more immediate health risk.

A. Compare the weight with what it was at last visit. B. Report serum potassium to healthcare provider. C. Review the dietary history from the past week. D. Check the pretibial areas and ankles for edema.

Correct Answer is B

Explanation

A. While weight monitoring is important for heart failure management, it's not the priority in this situation. The low potassium level is a more immediate concern.
B. The serum potassium level of 2.9 mEq/L is significantly below the normal range and indicates hypokalemia. Hypokalemia can lead to serious cardiac arrhythmias, especially in patients taking cardiac glycosides. This is a critical finding that requires immediate attention from the healthcare provider.
C. Dietary intake can contribute to potassium levels, but it's not the most urgent action at this time.
D. Assessing for edema is important for monitoring heart failure status, but it's not the priority when there's a critical electrolyte imbalance.

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While assessing a client with type 2 diabetes mellitus (DM), the nurse observes an absence of hair growth on the client's lower legs. Which assessment provides further data to support this finding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

Correct Answer is B

Explanation

Two weeks following a Billroth II (gastrojejunostomy), a client develops nausea, diarrhea, and diaphoresis after every meal. When the nurse develops a teaching plan for this client, which expected outcome statement is the most relevant?

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While changing the dressing of a client who is immobile, the nurse notices the boundary of the wound has increased. Before reporting this finding to the healthcare provider, the nurse should evaluate which of the client's laboratory values?