Which assessment finding leads the nurse to add risk for poisoning to the patient’s care plan?

Choice A reason: This is incorrect. Total urinary incontinence related to inability to feel urge to urinate is not appropriate for a patient with xerostomia. Xerostomia is the condition of having a dry mouth due to reduced or absent saliva production. It does not affect the urinary system or the sensation of bladder fullness.

Choice B reason: This is correct. Impaired oral mucous membranes related to decreased salivation and dry mouth is appropriate for a patient with xerostomia. Xerostomia can cause oral mucous membranes to become dry, cracked, inflamed, or infected. It can also affect the patient's ability to chew, swallow, speak, or taste.

Choice C reason: This is incorrect. Bathing self-care deficit related to inability to perceive left-sided body parts is not appropriate for a patient with xerostomia. Xerostomia does not affect the patient's perception of body parts or the ability to perform bathing activities.

Choice D reason: This is incorrect. Disturbed sensory perception related to feeling of electric pain in feet and hands is not appropriate for a patient with xerostomia. Xerostomia does not cause electric pain in the extremities. This symptom may be related to a nerve disorder, such as peripheral neuropathy.

Choice A reason: This is the correct choice because presence of pedal pulses and intact sensation is the most important bath time assessment of the diabetic patient. Pedal pulses are the pulses that can be felt on the top or side of the foot, and they indicate the blood flow to the lower extremities. Intact sensation is the ability to feel touch, pain, temperature, and vibration on the skin, and it indicates the nerve function of the lower extremities. Diabetic patients are at risk of developing peripheral vascular disease and peripheral neuropathy, which can impair the blood flow and nerve function of the lower extremities, and lead to ulcers, infections, or amputations. The nurse should assess the pedal pulses and intact sensation of the diabetic patient regularly, especially before and after bathing, to monitor for any signs of complications or deterioration.

Choice B reason: This is an incorrect choice because presence of fingernail clubbing is not the most important bath time assessment of the diabetic patient. Fingernail clubbing is a condition where the nails become curved and enlarged, and the nail bed becomes soft and spongy. It is a sign of chronic hypoxia or low oxygen levels in the blood, and it can be associated with various diseases such as lung cancer, cystic fibrosis, or congenital heart defects. However, it is not a common or specific complication of diabetes, and it does not pose an immediate risk of harm or injury to the diabetic patient.

Choice C reason: This is an incorrect choice because presence of abdominal rebound tenderness is not the most important bath time assessment of the diabetic patient. Abdominal rebound tenderness is a sign of peritoneal inflammation, which is the inflammation of the membrane that lines the abdominal cavity and organs. It is elicited by pressing and releasing the abdomen quickly, and it causes pain when the pressure is released. It can be caused by various conditions such as appendicitis, diverticulitis, or peritonitis. However, it is not a common or specific complication of diabetes, and it does not pose an immediate risk of harm or injury to the diabetic patient.

Choice D reason: This is an incorrect choice because presence of any petechiae or bruises is not the most important bath time assessment of the diabetic patient. Petechiae are small, red, or purple spots on the skin that are caused by bleeding under the skin. Bruises are larger, blue, or purple areas on the skin that are caused by bleeding under the skin. They can be caused by various factors such as trauma, infection, medication, or blood disorders. However, they are not a common or specific complication of diabetes, and they do not pose an immediate risk of harm or injury to the diabetic patient.