The nurse is assessing the deep tendon reflexes of a client with long-standing diabetes mellitus. Which clinical manifestation does the nurse expect to see?
a. Bilateral hypoactive reflexes
b. Bilateral hyperactive reflexes
c. Asymmetric reflex response
d. Bilateral ankle clonus
A
Long-standing diabetes mellitus causes peripheral neuropathy. Hypoactive responses or no re-sponse to stimulation of deep tendon reflexes is one manifestation of diabetes-induced peripheral neuropathy. Other responses are not related to complications of diabetes mellitus.
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The nurse is watching a new graduate nurse perform auscultation of a patient's abdomen. Which statement by the new graduate shows a correct understanding of the reason auscultation precedes percussion and palpation of the abdomen?
a. "We need to determine the areas of tenderness before using percussion and palpation." b. "Auscultation prevents distortion of bowel sounds that might occur after percussion and palpation." c. "Auscultation allows the patient more time to relax and therefore be more comfortable with the physical examination." d. "Auscultation prevents distortion of vascular sounds, such as bruits and hums, that might occur after percussion and palpation."
A nursing student has achieved academic excellence and has been invited to join nursing's honor society. Which organization has this student been invited to join?
1. National League for Nursing 2. American Nurses Association 3. Sigma Theta Tau International 4. American Association of Colleges of Nursing
The nurse explaining the pieces of a tracheostomy to a client would note that the portion of the tracheostomy apparatus used to round the end of the tube for insertion is the
a. flange. b. inner cannula. c. obturator. d. pilot tube.
The nurse is considering the use of restraints for a client. In which situation can the nurse apply restraints to a client?
1. Client wanders around the care area. 2. Client is picking at the access site for intravenous infusion of chemotherapy. 3. Client needed to use the bathroom and waited for help but didn't want to soil the bed and fell while attempting to walk to the bathroom. 4. Client does not want to stay in bed but wants to sit in the lounge with others.