A 45-year-old African-American client comes to the clinic complaining of fatigue, thirst, and frequent urination. During the physical exam, the nurse notices areas of linear hyperpigmentation around the neck and in the axillae (Acanthosis Nigricans). What would the nurse do next?
Refer the client for medical follow-up.
Ask the client about a family history of cancer.
Document the benign findings.
Perform a random blood sugar test.
The Correct Answer is A
Choice a reason :
Referring the client for medical follow-up is the most appropriate action. Acanthosis Nigricans is often associated with insulin resistance and is a risk factor for diabetes mellitus. The client's symptoms of fatigue, thirst, and frequent urination are classic signs of diabetes. Therefore, a comprehensive medical evaluation is necessary to rule out diabetes or other underlying conditions that could be causing these symptoms.
Choice b reason
While Acanthosis Nigricans can sometimes be associated with malignancy, it is more commonly linked to insulin resistance and diabetes. The client's presenting symptoms are not typical of cancer but are indicative of diabetes. Therefore, while a family history of cancer is relevant to the client's overall health, it is not the immediate concern based on the current presentation.
Choice c reason
Documenting findings is an essential part of the nursing process; however, the presence of Acanthosis Nigricans, especially when coupled with symptoms of fatigue, thirst, and frequent urination, should not be considered benign without further investigation. These findings warrant further assessment to determine the underlying cause.
Choice d reason
Performing a random blood sugar test could be a part of the initial assessment; however, it should not replace a referral for a comprehensive medical evaluation. A random blood sugar test alone may not be sufficient to diagnose diabetes or determine the cause of the client's symptoms. A full medical follow-up will likely include blood sugar testing along with other diagnostic tests.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason:
Acute pain is typically sudden in onset and is usually the result of a specific injury or illness. It is characterized by its sharp quality and tends to last for a short duration, generally not longer than six months. Since the patient's knee pain has persisted for eleven months, it does not fall under the category of acute pain.
Choice B reason:
Intermittent pain is pain that comes and goes at intervals. Although the patient's pain could be intermittent, the classification based on duration would not be described as intermittent. This term refers more to the pattern of the pain rather than its chronicity or cause.
Choice C reason:
Chronic pain is defined as pain that persists for longer than six months, often continuing even after the injury or illness that caused it has healed. The patient's bilateral knee pain has been present for eleven months, which exceeds the six-month threshold, thus categorizing it as chronic pain.
Choice D reason:
Idiopathic pain refers to pain that arises without a clear cause. It is not categorized based on the duration of the pain but rather on the absence of an identifiable underlying reason. Since the patient's pain has a specific duration, it is not appropriate to classify it as idiopathic without further information regarding its cause.
Correct Answer is D
Explanation
Choice a reason:
Bronchovesicular sounds are normal breath sounds heard over the main bronchus area and over the upper right posterior lung field. They have a medium pitch and intensity and are heard on both inspiration and expiration. Bronchovesicular sounds do not involve the change of vowel sounds during auscultation.
Choice b reason:
Bronchophony is the term used when the voice sounds are more clear and louder over the chest wall, usually indicating lung consolidation. However, it does not specifically refer to the change of vowel sounds from "ee" to "ay."
Choice c reason:
Normal voice resonance is when voice sounds heard through auscultation are muffled and indistinct. It does not involve a clear change in vowel sounds, which is what occurs with egophony.
Choice d reason:
Egophony is characterized by the change of the "ee" vowel sound to a nasal "ay" or "a" sound when auscultating the lungs. This phenomenon typically suggests lung consolidation, as might be seen with pneumonia.
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