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A nurse in the outpatient clinic is assessing a client who has psoriasis. The nurse should expect which of the following findings?
- A. Silvery, white scales.
- B. Intense pain.
- C. Unilateral lesions.
- D. Serous drainage.
Correct Answer: A
Rationale: The correct answer is A: Silvery, white scales. Psoriasis is characterized by the presence of silvery, white scales on the skin due to rapid skin cell turnover. This finding is classic for psoriasis. Intense pain (B) is not a typical symptom of psoriasis; it is more commonly associated with conditions like shingles. Unilateral lesions (C) would not be expected in psoriasis, as it often affects both sides of the body symmetrically. Serous drainage (D) is not a typical feature of psoriasis, which primarily presents with dry, scaly patches.
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A nurse is assessing a client. Which of the following actions should the nurse take to assess the posterior tibial pulse? (Select all that apply.)
- A. Palpate the area behind the ankle bone.
- B. Use the pads of the fingers to feel for the pulse.
- C. Compare the pulse strength with the other leg.
- D. Assess for any swelling or tenderness.
Correct Answer: A,B,C
Rationale: The correct actions to assess the posterior tibial pulse are A, B, and C. A: Palpating the area behind the ankle bone locates the posterior tibial pulse accurately. B: Using the pads of the fingers helps to detect the pulse's strength and regularity. C: Comparing pulse strength with the other leg enables the nurse to identify any discrepancies. D: Assessing for swelling or tenderness is not directly related to locating the pulse. Therefore, choices D, E, F, and G are incorrect for assessing the posterior tibial pulse.
Upon assessment, Cullen’s sign is noted. What complication of acute pancreatitis would the nurse suspect that the client might have?
- A. Pancreatic pseudocyst.
- B. Electrolyte imbalance.
- C. Internal bleeding.
- D. Pleural effusion.
Correct Answer: C
Rationale: Rationale: Cullen's sign is bluish discoloration around the umbilicus, indicating internal bleeding in acute pancreatitis. This occurs due to retroperitoneal hemorrhage tracking to the periumbilical area. Choices A, B, and D are not associated with Cullen's sign. Pancreatic pseudocyst may present with epigastric pain, electrolyte imbalance with nausea and vomiting, and pleural effusion with dyspnea.
A nurse is assessing a client who has rheumatoid arthritis. Which of the following findings should the nurse expect?
- A. Unilateral joint involvement.
- B. Ulnar deviation.
- C. Decreased sedimentation rate.
- D. Fractures of the spine.
Correct Answer: B
Rationale: The correct answer is B: Ulnar deviation. In rheumatoid arthritis, ulnar deviation of the fingers is a common finding due to inflammation and destruction of the joints. This deformity leads to the fingers deviating towards the ulnar side of the hand. This is a characteristic feature seen in rheumatoid arthritis and is caused by the inflammation affecting the joints. Choices A, C, and D are incorrect. A: Unilateral joint involvement is not typical of rheumatoid arthritis, as it usually affects multiple joints symmetrically. C: Decreased sedimentation rate is not expected in rheumatoid arthritis, as it is typically associated with an elevated sedimentation rate due to inflammation. D: Fractures of the spine are not a common finding in rheumatoid arthritis, as it primarily affects the joints.
A nurse in an emergency department is caring for a client who has deep partial- and full-thickness burns to his face, chest, abdomen, and upper arms. What is the nurse’s priority intervention for this client during the resuscitation phase of injury?
- A. Medicate for pain.
- B. Maintain the airway.
- C. Insert an indwelling urinary catheter.
- D. Initiate fluid resuscitation.
Correct Answer: B
Rationale: The correct answer is B: Maintain the airway. During the resuscitation phase of burn injuries, priority is given to ensuring airway patency to prevent respiratory distress and failure. Burns to the face, chest, and abdomen can lead to airway compromise due to swelling and damage. Maintaining the airway is crucial to ensure adequate oxygenation and ventilation. Pain management (choice A) is important but not the priority in this phase. Inserting a urinary catheter (choice C) is not a priority during the resuscitation phase. Initiating fluid resuscitation (choice D) is important but only after ensuring airway patency.
A client seeks medical attention for intermittent signs and symptoms that suggest a diagnosis of Raynaud’s disease. The nurse should assess the trigger of these signs/symptoms by asking which?
- A. Does drinking coffee or ingesting chocolate seem related to the episodes?
- B. Does being exposed to heat seem to cause the episodes?
- C. Do the signs and symptoms occur while you are asleep?
- D. Have you experienced any injuries that have limited your activity levels lately?
Correct Answer: A
Rationale: The correct answer is A: Does drinking coffee or ingesting chocolate seem related to the episodes? This question is relevant because caffeine and chocolate are known triggers for Raynaud's disease due to their vasoconstrictive properties. By asking about these specific triggers, the nurse can gather important information to help identify potential causes of the client's symptoms.
Choice B is incorrect because exposure to heat typically alleviates symptoms of Raynaud's disease rather than causing them. Choice C is irrelevant as Raynaud's symptoms typically occur when the individual is exposed to cold or experiencing stress, not while asleep. Choice D is also incorrect as injuries limiting activity levels are not directly related to Raynaud's disease triggers.