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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Wearing gloves before touching the client is not necessary unless the nurse anticipates contact with bodily fluids, non-intact skin, or mucous membranes.
B. Using a separate, disposable blood pressure cuff is an example of transmission-based precautions, not standard precautions, unless the client has an infection requiring contact precautions.
C. Wearing gloves to palpate the tongue and buccal membranes is correct because standard precautions require gloves when there is potential contact with mucous membranes, which can expose the nurse to infectious agents.
D. Wearing a gown, gloves, and mask is unnecessary unless the client has an infection that requires additional precautions beyond standard precautions.
Correct Answer is C
Explanation
A. Documenting bradycardia is incorrect because the client is experiencing tachycardia (HR 108), not bradycardia.
B. Applying oxygen at 2L/min is incorrect because the oxygen saturation is normal (96% on room air). Oxygen therapy is not indicated at this time.
C. Reassess the vital signs in five minutes is correct because the slightly elevated heart rate and respiratory rate may be due to recent physical activity after prolonged bedrest. It is important to allow the client time to recover and reassess before taking further action.
D. Notifying the provider is incorrect because there is no immediate concern; the elevated HR and RR are expected post-activity.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.