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?

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.

A. Pressing over the shins to measure indentation is a technique used to assess for edema, not muscle atrophy. Edema refers to fluid accumulation in the tissues, which can cause an indentation when pressed, whereas muscle atrophy involves a reduction in muscle mass and would not be detected by this method.
B. A goniometer is a tool used to measure the range of motion of joints, not muscle size. While it can be useful in assessing joint mobility and flexibility, it does not provide information about muscle mass or atrophy.
C. Comparing the appearance of the legs bilaterally is an appropriate method to assess for muscle atrophy. By visually inspecting and palpating both legs, the nurse can identify differences in muscle bulk and size. Muscle atrophy often presents as noticeable asymmetry between the two legs, with one leg appearing smaller or thinner compared to the other.
D. Observing the client during heel-toe ambulation can help assess gait and functional mobility, but it is not the most direct method for evaluating muscle atrophy. While gait abnormalities can suggest underlying muscle weakness or atrophy, direct visual and palpation comparison of muscle mass provides a clearer assessment of muscle atrophy.