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

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A reason: This is incorrect. Neuropathy due to uncontrolled diabetes is not an example of nociceptive pain. Neuropathy is a type of neuropathic pain, which is pain that is caused by damage or dysfunction of the nervous system. It can cause sensations of numbness, tingling, burning, or shooting pain in the affected area. It is not related to tissue injury or inflammation.

Choice B reason: This is incorrect. Phantom pain after amputation of a limb is not an example of nociceptive pain. Phantom pain is a type of neuropathic pain, which is pain that is felt in a body part that is no longer present. It can be triggered by memories, emotions, or stimuli. It is not related to tissue injury or inflammation.

Choice C reason: This is correct. Pain from rheumatoid arthritis joint damage is an example of nociceptive pain. Nociceptive pain is pain that is caused by tissue injury or inflammation. It can be triggered by mechanical, thermal, or chemical stimuli. It can cause sensations of aching, throbbing, or stabbing pain in the affected area.

Choice D reason: This is incorrect. Chronic nerve pain after shingles infection is not an example of nociceptive pain. Chronic nerve pain is a type of neuropathic pain, which is pain that is caused by damage or dysfunction of the nervous system. It can be caused by a viral infection, such as shingles, that affects the nerve fibers. It can cause sensations of burning, itching, or electric pain in the affected area. It is not related to tissue injury or inflammation.

A. Teach the patient to wear low-heeled, comfortable, supportive footwear at all times. B. Encourage the patient to participate in tai chi exercises to promote balance. C. Evaluate the patient's blood pressure for orthostatic hypotension. D. Instruct the patient to wear a medical alert bracelet that identifies risk for falls.

Correct Answer is A

Explanation

Choice A reason: This is correct. Teaching the patient to wear low-heeled, comfortable, supportive footwear at all times is the highest priority intervention for a patient with diabetic neuropathy who has lost sensation in both feet. This can prevent foot injuries, ulcers, and infections that can lead to amputation.

Choice B reason: This is incorrect. Encouraging the patient to participate in tai chi exercises to promote balance is a beneficial intervention for a patient with diabetic neuropathy who has lost sensation in both feet, but not the highest priority. Tai chi can improve muscle strength, coordination, and flexibility, but it does not protect the feet from injury.

Choice C reason: This is incorrect. Evaluating the patient's blood pressure for orthostatic hypotension is an important intervention for a patient with diabetic neuropathy who has lost sensation in both feet, but not the highest priority. Orthostatic hypotension is a condition where the blood pressure drops when the patient changes position, causing dizziness and fainting. It can be caused by autonomic neuropathy, which affects the nerves that control blood pressure and heart rate.

Choice D reason: This is incorrect. Instructing the patient to wear a medical alert bracelet that identifies risk for falls is a helpful intervention for a patient with diabetic neuropathy who has lost sensation in both feet, but not the highest priority. A medical alert bracelet can alert emergency personnel of the patient's condition and medications, but it does not prevent falls or foot injuries.

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Which bath time assessment of the diabetic patient is most important?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which is an example of nociceptive pain?

Correct Answer is C

Explanation

Which is the highest priority intervention for a patient with diabetic neuropathy who has lost sensation in both feet?

Correct Answer is A

Explanation

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