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 C

Explanation

A. A decreased pleural effusion on a chest x-ray is generally a positive outcome following a thoracentesis. It indicates that the procedure was successful in removing the excess fluid. This finding does not warrant immediate intervention and is expected after the procedure.
B. The pH of 7.35 indicates acidosis (normal range is 7.35 to 7.45). The PaCO₂ is on the lower end of normal, suggesting that if there is an acid-base imbalance, it might be metabolic or mixed. The HCO₃⁻ is within normal limits, indicating no metabolic component. The PaO₂ is slightly below the normal range (80-100 mm Hg), which could be a concern but is not critically low.
C. Asymmetrical chest wall expansion can indicate a complication such as pneumothorax (air in the pleural space), which could occur as a complication of thoracentesis. This finding warrants immediate intervention because it may signify a serious issue that requires prompt attention, such as the need for a chest tube or further evaluation.
D. Pain at the insertion site is expected following a thoracentesis and is generally not an urgent concern unless it is severe or associated with other symptoms like fever, difficulty breathing, or signs of infection. This type of pain is usually managed with analgesics and does not typically require immediate intervention unless accompanied by more serious symptoms.

A. Straining on urination and nocturia B. Azotemia and anorexia. C. Hematuria and proteinuria. D. Fever and dysuria.

Correct Answer is D

Explanation

A. These symptoms indicate a urinary tract issue but do not necessarily indicate a high risk for injury. While they are uncomfortable, they do not typically lead to physical harm.
B. Azotemia is the build-up of waste products in the blood, and anorexia is a loss of appetite. These symptoms indicate a more severe kidney problem and do not specifically point to an increased risk of injury due to a potential UTI.
C. These symptoms suggest kidney involvement but do not necessarily indicate an imminent risk of injury. While they are important to address, they do not warrant the nursing problem of "high risk for injury due to potential urinary tract infection."

D. Fever and dysuria are classic symptoms of a urinary tract infection (UTI). A UTI can progress to a more serious infection, such as pyelonephritis, which can lead to sepsis and potentially life-threatening complications. Therefore, these symptoms indicate a high risk for injury due to the potential for a UTI to worsen.

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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?

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Naxlex Comprehensive Predictor Exams

A client with a large pleural effusion undergoes a thoracentesis. Following the procedure, which observation warrants immediate intervention by the nurse? Reference Range: Arterial Blood Gas (ABG) pH [7.35 to 7.45] PaCO, [35 to 45 mm Hg] HCO 21 to 28 mEq/L (21 to 28 mmol/L)] PaO2 [80 to 100 mm Hg]

Correct Answer is C

Explanation

The nurse is evaluating a client's symptoms, and formulates the nursing problem, "High risk for injury due to potential urinary tract infection." Which symptoms indicate the need for this nursing problem?

Correct Answer is D

Explanation

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The nurse is assessing a client who is newly diagnosed with hypothyroidism. Which assessment finding requires immediate intervention?

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