Which bath time assessment of the diabetic patient is most important?
Presence of pedal pulses and intact sensation
Presence of fingernail clubbing
Presence of abdominal rebound tenderness
Presence of any petechiae or bruises
The Correct Answer is A
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: This is incorrect. The PCA will not give additional pain medication whenever the button is pushed. The PCA is programmed to deliver a specific dose of pain medication at a specific interval. If the button is pushed before the interval is over, the PCA will not release any medication. This is to prevent overdose and side effects.
Choice B reason: This is incorrect. The PCA will not deliver medication through the IV until the pain is all gone. The PCA is designed to provide pain relief, not pain elimination. The PCA has a limit on how much medication it can deliver in a certain period of time. The patient may still have some pain even after using the PCA.
Choice C reason: This is correct. You or a designated family member are the only one who gets to push the PCA button-nobody else may do so. The PCA is intended to give the patient control over their pain management. The patient should push the button when they feel pain, not when someone else thinks they need it. Allowing others to push the button can lead to under- or over-medication, which can be harmful.
Choice D reason: This is incorrect. Wait until the pain becomes severe before pushing the PCA button is not a good instruction. The PCA is more effective when the patient pushes the button before the pain becomes too intense. Waiting too long can make the pain harder to control and require more medication. The patient should use the PCA as needed to keep the pain at a tolerable level..
Correct Answer is ["C","D","E"]
Explanation
Choice A reason: This is incorrect. The patient takes 30 mg morphine sulfate daily does not lead the nurse to clarify the order for ibuprofen 600 mg PO every 8 hours. Morphine sulfate is an opioid analgesic that can be used in combination with ibuprofen, a nonsteroidal anti-inflammatory drug (NSAID), for moderate to severe pain. The nurse should monitor the patient for signs of respiratory depression, sedation, or constipation, but there is no need to clarify the order.
Choice B reason: This is incorrect. The patient has severe joint pain due to aggressive arthritis does not lead the nurse to clarify the order for ibuprofen 600 mg PO every 8 hours. Ibuprofen is indicated for the relief of signs and symptoms of rheumatoid arthritis and osteoarthritis. The nurse should assess the patient's pain level, response to treatment, and adverse effects, but there is no need to clarify the order.
Choice C reason: This is correct. The patient has a gastrointestinal bleed leads the nurse to clarify the order for ibuprofen 600 mg PO every 8 hours. Ibuprofen can cause gastrointestinal irritation, ulceration, bleeding, and perforation. The nurse should question the order and consider alternative analgesics for the patient, especially if they have a history of peptic ulcer disease, gastritis, or bleeding disorders.
Choice D reason: This is correct. The patient has a history of diabetes and early renal failure leads the nurse to clarify the order for ibuprofen 600 mg PO every 8 hours. Ibuprofen can impair renal function, increase blood pressure, and interfere with the effects of antihypertensive and antidiabetic drugs. The nurse should question the order and monitor the patient's renal function, blood pressure, and blood glucose levels closely.
Choice E reason: This is correct. The patient has allergies to shellfish, strawberries, and iodine leads the nurse to clarify the order for ibuprofen 600 mg PO every 8 hours. Ibuprofen can cause hypersensitivity reactions, such as rash, angioedema, bronchospasm, or anaphylaxis. The nurse should question the order and ask the patient about any previous reactions to NSAIDs or aspirin. The patient may need to avoid ibuprofen and use a different analgesic..
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