A 45-year-old client with dark skin tone comes to the clinic complaining of fatigue, thirst, and frequent urination. During the examination, the nurse notices areas of hyperpigmentation around the neck and in the axillae. What is the priority intervention by the nurse?

Refer the client for medical follow-up in two weeks.

Document the benign findings.

Perform a random blood sugar test per order.

Ask the client about a family history of cancer.

Answer and Explanation

The Correct Answer is C

A. Delaying follow-up for two weeks is inappropriate when symptoms suggest a possible serious metabolic disorder, such as diabetes. Immediate testing is needed.
B. Simply documenting the findings as benign is incorrect because hyperpigmentation in these areas (acanthosis nigricans) can be a sign of insulin resistance, which requires further evaluation.
C. Performing a random blood sugar test per order is correct. The symptoms of fatigue, thirst, and frequent urination, along with acanthosis nigricans, strongly suggest diabetes mellitus or insulin resistance. A random blood glucose test can help determine if the client has hyperglycemia.
D. While certain malignancies can be associated with acanthosis nigricans, diabetes is a more common cause. Asking about cancer history is not the priority intervention.

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Correct Answer is B

Explanation

A. This is incorrect because it describes an actual nursing diagnosis, not a risk diagnosis.
B. A risk diagnosis describes a situation in which a problem will likely occur if the nurse does not intervene. It identifies a potential health problem that has not yet developed but could occur due to the client’s risk factors.
C. This is incorrect because it describes a health promotion diagnosis, which focuses on enhancing well-being rather than preventing a problem.
D. This is incorrect because it describes a syndrome diagnosis, which is a group of related nursing diagnoses that occur together.

A. A 3-year-old child with fever, rash, and sore throat. B. A 45-year-old man with chest pain and diaphoresis for 1 hour. C. A 14-year-old girl who is crying because she thinks she is pregnant. D. A 20-year-old man with a 3-inch shallow laceration on his leg.

Correct Answer is B

Explanation

A. A 3-year-old with fever, rash, and sore throat should be evaluated promptly, but these symptoms do not necessarily indicate an immediate life-threatening emergency.
B. A 45-year-old man with chest pain and diaphoresis for 1 hour is the priority because these are classic symptoms of acute coronary syndrome (ACS) or myocardial infarction (MI). Immediate emergency assessment and intervention are required.
C. A 14-year-old girl crying about a possible pregnancy needs emotional support and counseling but does not require immediate emergency intervention.
D. A 20-year-old man with a 3-inch shallow laceration on his leg needs wound care, but his condition is not life-threatening and does not require emergency assessment.

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A 45-year-old client with dark skin tone comes to the clinic complaining of fatigue, thirst, and frequent urination. During the examination, the nurse notices areas of hyperpigmentation around the neck and in the axillae. What is the priority intervention by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nursing student correctly describes a risk diagnosis by which of the following statements?

Correct Answer is B

Explanation

The nurse is working in an ambulatory care clinic that is located in a busy, inner-city neighborhood. Which client would the nurse determine to be in most need of an emergency assessment?

Correct Answer is B

Explanation

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