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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice a reason:
A BMI of 27 falls into the 'Overweight' category according to the standard BMI classification. The 'Overweight' range is defined as a BMI of 25 to 29.9. This indicates that the person's weight is higher than what is considered healthy for a given height.

Choice b reason:
'Obesity Class I' is characterized by a BMI of 30 to 34.9. Since the client's BMI is 27, it does not reach the threshold for this category.

Choice c reason:
The 'Normal weight' category ranges from a BMI of 18.5 to 24.9. With a BMI of 27, the client exceeds the upper limit of the normal weight range.

Choice d reason:
The term 'Obesity' generally refers to a BMI of 30 or higher, which encompasses Obesity Class I, II, and III. Since the client's BMI is 27, it is below the obesity range.

A. Oral mucosa B. Ear lobes C. Soles of the feet D. Conjunctivae

Correct Answer is A

Explanation

Choice a reason:
The oral mucosa is the most reliable area to evaluate for central cyanosis in a client with asthma. Central cyanosis reflects a decrease in arterial oxygenation and is best assessed where the blood flow is high and the skin is thin, which is the case with the oral mucosa. It is less likely to be affected by peripheral factors such as temperature and is therefore a more accurate indicator of oxygen saturation in the central circulation.

Choice b reason:
While ear lobes can show signs of cyanosis, they are not the most reliable indicator of central cyanosis because they are more prone to peripheral cyanosis. Peripheral cyanosis can occur in the ear lobes due to local vasoconstriction or decreased blood flow, which may not reflect central oxygenation levels.

Choice c reason:
The soles of the feet are not a reliable indicator of central cyanosis, especially in a client with asthma. The skin on the soles is thicker and has less blood flow compared to the oral mucosa, making it a poor site for assessing central cyanosis. Additionally, the soles can be affected by peripheral factors like pressure and temperature.

Choice d reason:
Conjunctivae are not the most reliable indicator of central cyanosis. While they can show signs of cyanosis, the assessment can be affected by environmental factors and the presence of blood vessels in the conjunctiva that may not accurately reflect central oxygenation levels.

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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?

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Naxlex Comprehensive Predictor Exams

Using the client's height of 72 inches and weight of 200 lbs, the nurse calculates the BMI. A BMI of 27 indicates which category for this patient?

Correct Answer is A

Explanation

A nurse is assessing a client who has asthma. Which of the following areas should the nurse evaluate as the most reliable indicator of central cyanosis?

Correct Answer is A

Explanation

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A nurse educator is presenting at a continuing education seminar for nurses. As part of his presentation, he is emphasizing the prevention of skin breakdown in immobile patients who have suffered from a stroke. The level of prevention being discussed by the nurse educator is:

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?

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