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 B

Explanation

A. Skin elasticity is assessed by pinching the skin to see how quickly it returns to its normal position, which is often done to evaluate hydration status or the presence of dehydration. While skin elasticity is an important overall assessment of skin health, it is not directly related to the assessment of erythema.
B. Palpating the erythematous area for warmth and swelling is a crucial follow-up assessment. Erythema (redness of the skin) can be a sign of inflammation or infection, and the presence of warmth and swelling can help determine if the area is inflamed or if there might be an underlying infection.
C. Oxygen saturation measurements assess the level of oxygen in the blood, typically using a pulse oximeter. While oxygen saturation is important for assessing overall respiratory and circulatory health, it is not directly related to evaluating the cause or characteristics of erythema. Therefore, this would not be the most relevant follow-up assessment for a red area on the skin.
D. Observing the appearance of the nailbeds can provide information about overall circulation and oxygenation, but it is not directly related to assessing a localized area of erythema on the skin. Changes in the nailbeds can indicate systemic conditions but would not provide specific information about the erythematous area in question.

A. Ask the client to swallow while palpating along the sides of the trachea. B. Palpate deeply and firmly over the location of the thyroid gland. C. Document that thyroid gland size is normal with no visible goiter. D. Defer the thyroid exam and observe the client for signs of myxedema.

Correct Answer is A

Explanation

A. Asking the client to swallow while palpating along the sides of the trachea helps in assessing the thyroid gland's size and mobility. The thyroid gland is located just below the larynx, and during swallowing, it moves upward, which can make it easier to palpate and identify any enlargement or nodules.
B. Palpating deeply and firmly might not be necessary and could be uncomfortable for the client. Gentle palpation is usually adequate for assessing the thyroid gland. Excessive force is not recommended as it may not yield additional information and could cause discomfort.
C. If the thyroid gland is not visible, documenting that it is normal without further assessment may not be accurate. The gland could be enlarged (goiter) or have other abnormalities that are not apparent on visual inspection alone. Accurate documentation should include findings from palpation and other assessment techniques.
D. Deferring the thyroid exam and focusing on signs of myxedema is not ideal in this situation. Myxedema is a severe form of hypothyroidism that can have various signs, but the immediate need is to assess the thyroid gland directly for goiter or other abnormalities. It is essential to perform a thorough examination and not rely solely on observation of symptoms that might appear later.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When inspecting a client's skin, the nurse observes an area of erythema on the arm. Which follow- up assessment should the nurse complete?

Correct Answer is B

Explanation

The nurse is assessing a client for goiter and is unable to observe the thyroid gland. Which action should the nurse take?

Correct Answer is A

Explanation

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