The nurse is assessing a client with type 2 diabetes mellitus and observes an abnormal response when using a monofilament. Which finding should the nurse document that is consistent with an abnormal finding?

Inequality in muscle contraction.

An intention tremor.

Slowed capillary refill.

Loss of peripheral sensation.

Answer and Explanation

The Correct Answer is D

A.   Inequality in muscle contraction is not related to the monofilament test, which assesses sensation rather than muscle strength or contraction. This finding would be more relevant to a neurological or musculoskeletal assessment rather than a sensory test.
B.   An intention tremor is a type of tremor that occurs when a person is trying to make a precise movement, often associated with conditions affecting the cerebellum. This is not related to the monofilament test, which measures sensory perception and not motor function or tremors.

C.   Slowed capillary refill is a sign of poor peripheral circulation and is assessed by pressing on the nail bed or skin and observing how long it takes for color to return. While it is important for assessing blood flow, it is not directly related to the monofilament test, which evaluates sensory function.
D.   Loss of peripheral sensation is a direct and relevant finding for an abnormal response on the monofilament test. The monofilament test is designed to detect loss of sensation in the feet, which can be an indicator of diabetic neuropathy. An abnormal result, such as the inability to feel the monofilament or diminished sensation in certain areas, would indicate that the client is experiencing peripheral neuropathy.

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Correct Answer is C

Explanation

A. Being oriented x 3 means the client is aware of their name, the current time (or day), and the location (place). In this case, since the client is only able to remember his name and where he is, but not the time, day, or date, this documentation would be incorrect. The client does not meet the criteria for being oriented x 3.
B. Being oriented x 1 means the client is aware of only one aspect of orientation, such as their name. Since the client is able to remember both his name and his location, documenting as oriented x 1 would not fully capture the extent of the client's orientation. The client is oriented to more than one aspect.
C. Being oriented x 2 means the client is aware of two aspects of orientation. In this case, since the client is able to remember his name and his location (but not the time, day, or date), documenting as oriented x 2 accurately reflects his level of orientation.
D. Being oriented x 4 means the client is aware of four aspects: their name, the current time (or day), the date, and the location. Given that the client can only remember his name and location, this
documentation would be incorrect as it does not align with the client’s current state of orientation.

A. "Can you recall the date the Twin Towers in New York were destroyed?" B. "What is the difference between a hamster and a rabbit as a pet?" C. "Should someone who lives in a glass house throw stones?" D. "Do you write checks if you know the bank account is overdrawn?"

Correct Answer is C

Explanation

A. This question assesses a client's recent memory, not their judgment.
B. This question assesses a client's knowledge and understanding of animals, not their judgment.
C. This question evaluates a client's judgment by assessing their ability to make sound decisions based on hypothetical situations. It requires the client to consider potential consequences and make a logical inference.
D. This question assesses a client's financial knowledge and decision-making skills, but it doesn't directly evaluate their judgment in a hypothetical situation.

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The nurse is assessing a client with type 2 diabetes mellitus and observes an abnormal response when using a monofilament. Which finding should the nurse document that is consistent with an abnormal finding?

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