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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Spicy foods can exacerbate GERD symptoms by irritating the esophagus and increasing acid production. While minimizing spicy foods is important, it is one of several dietary changes that can help manage GERD. It’s beneficial but may not be the single most critical instruction compared to other lifestyle modifications.
B. Remaining upright after meals is crucial for managing GERD. Lying down or reclining too soon after eating can allow stomach acid to flow back into the esophagus, worsening symptoms. Staying upright helps to facilitate digestion and reduce acid reflux, making this practice highly important for symptom control and prevention of reflux.
C. Tight-fitting clothes can increase abdominal pressure, which may contribute to the occurrence of acid reflux. While this is a helpful instruction to prevent exacerbation of symptoms, it may not be as directly impactful as remaining upright after meals.
D. Smoking can weaken the lower esophageal sphincter (LES), making it easier for stomach acid to reflux into the esophagus. However, while important, this instruction might be considered a secondary priority compared to immediate practical strategies like maintaining an upright position after eating.
Correct Answer is B
Explanation
A. This action is typically used in the treatment of hyperkalemia (high potassium levels), not hypokalemia. The combination of glucose and insulin is used to temporarily drive potassium into cells and lower serum potassium levels. For severe hypokalemia, the priority is to administer potassium replacement therapy rather than attempting to lower potassium levels, as the client needs to correct the deficiency.
B. Severe hypokalemia requires prompt correction to prevent complications. Potassium replacement should be administered according to healthcare provider orders. This may involve oral or intravenous potassium supplements, depending on the severity of the hypokalemia and the client's condition. Informing the healthcare provider is essential for ensuring that appropriate and timely treatment is provided.
C. While increasing potassium intake through diet is important for managing mild cases of hypokalemia, a serum potassium level of 2.5 mEq/L is severe and likely requires immediate medical intervention. Dietary changes alone are insufficient and not timely enough to address such a critical deficiency.
D. Monitoring urinary output is important in managing electrolyte imbalances to assess kidney function and fluid balance, but it is not the primary intervention for severe hypokalemia. The immediate priority is to address the low potassium level through appropriate replacement therapy.
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