The nurse observes that the lower legs of a client with diabetes mellitus are shiny with no hair growth. To obtain additional data to support these findings, which assessment should the nurse perform?

Palpate the client's dorsalis pedis pulses.

Ask If the client often feels weak or hungry.

Compare the range of motion of both legs.

Measure the client's capillary glucose.

Answer and Explanation

The Correct Answer is A

Choice A Reason:
Palpating the client's dorsalis pedis pulses is appropriate because shiny lower legs with no hair growth are characteristic findings of peripheral arterial disease (PAD), which commonly occurs in individuals with diabetes mellitus. Palpating the client's dorsalis pedis pulses allows the nurse to assess peripheral arterial perfusion. Weak or absent dorsalis pedis pulses may indicate decreased blood flow to the feet and lower extremities, supporting the diagnosis of PAD.
Choice B Reason:
Asking if the client often feels weak or hungry is less relevant to the assessment findings of shiny lower legs with no hair growth. While it is important to assess for symptoms of hypoglycemia in clients with diabetes mellitus, such as weakness or hunger, these symptoms do not directly correlate with the observed peripheral vascular changes.
Choice C Reason:
Comparing the range of motion of both legs is less relevant to the assessment findings of shiny lower legs with no hair growth. Range of motion assessment is important for assessing joint function and mobility but does not provide information specifically related to peripheral vascular status.
Choice D Reason:
Measuring the client's capillary glucose is less relevant to the assessment findings of shiny lower legs with no hair growth. While it is important to monitor blood glucose levels in clients with diabetes mellitus, capillary glucose measurement does not provide information specifically related to peripheral vascular status or the observed findings of PAD.

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Correct Answer is B

Explanation

Choice A Reason:
Recently had dental surgery is incorrect. Dental surgery may involve procedures that could cause minor trauma to the oral tissues, leading to localized bruising (ecchymosis) around the mouth or jaw area. However, this localized bruising would typically not explain the presence of ecchymosis observed on the trunk and extremities. Therefore, while dental surgery may be relevant to the client's overall health history, it is less likely to directly relate to the widespread ecchymosis observed.
Choice B Reason:
Takes an oral anticoagulant is correct. Taking an oral anticoagulant medication increases the risk of bleeding, which can manifest as ecchymosis (bruising) on the skin. Anticoagulants such as warfarin or aspirin can interfere with the blood's ability to clot, leading to bleeding into the skin and subsequent ecchymosis. Therefore, this information is particularly important to follow up on as it may directly contribute to the observed ecchymosis.
Choice C Reason:
Adheres to a gluten-free diet is incorrect. Adhering to a gluten-free diet is typically related to managing celiac disease or gluten intolerance, which primarily affects the gastrointestinal tract. While celiac disease can be associated with certain skin conditions, ecchymosis is not a typical manifestation of gluten intolerance. Therefore, while this information may be relevant to the client's overall health, it is less likely to directly explain the observed ecchymosis.
Choice D Reason:
Works in a day care center is incorrect. Working in a day care center may involve activities that could result in minor injuries or bruises, but it is less likely to explain widespread ecchymosis observed on the trunk and extremities. While accidental injuries are possible in a daycare setting, they would typically be localized and not widespread. Therefore, while this information may be relevant to the client's occupation and risk of injury, it is less likely to directly relate to the observed ecchymosis.

A. Check the reading after the other nurse leaves the room. B. Document a pulse deficit of 16 beats per minute. C. Report the results of the deficit to the healthcare provider. D. Repeat the assessment to obtain another reading.

Correct Answer is D

Explanation

Choice A Reason:
Checking the reading after the other nurse leaves the room is inappropriate. This option suggests waiting until the other nurse leaves to check the reading again. However, there's no guarantee that the discrepancy will resolve itself, and waiting might delay necessary intervention if there is indeed a pulse deficit. Therefore, this option does not address the immediate need for clarification.
Choice B Reason:
Documenting a pulse deficit of 16 beats per minute is inappropriate. While there appears to be a difference between the apical and radial pulse readings, it's important to verify the accuracy of the measurements before documenting a pulse deficit. Documenting without confirmation could lead to inaccurate information in the patient's medical record.
Choice C Reason:
Reporting the results to the healthcare provider without confirming the accuracy of the measurements may lead to unnecessary concern or intervention. It's essential to ensure that the findings are accurate before reporting them to the healthcare provider.
Choice D Reason:
Repeating the assessment to obtain another reading is appropriate. This option prioritizes patient safety by acknowledging the need to confirm the accuracy of the measurements. Repeating the assessment allows the nurses to ensure consistency and reliability in their findings before taking further action or reporting to the healthcare provider.
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The nurse observes that the lower legs of a client with diabetes mellitus are shiny with no hair growth. To obtain additional data to support these findings, which assessment should the nurse perform?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When inspecting the client's skin, the nurse observes several areas of ecchymosis on the trunk and extremities. Which information in the client's history requires additional follow-up by the nurse?

Correct Answer is B

Explanation

The primary nurse asks another nurse to assist in checking a client for an apical-radial pulse deficit. One nurse counts an apical pulse of 72 beats/minute while the other nurse counts a radial pulse of 88 beats/minute. Which action should the primary nurse take?

Correct Answer is D

Explanation

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