A client with red scaling papules on his elbows, knees, lower back, and scalp arrives to the clinic. Which of the following questions will the nurse include in her assessment?
Do the lesions hurt?
Do the lesions worsen when you eat certain foods?
Have you noticed a decrease in lesions after starting antibiotics?
How do you spend your weekends?
The Correct Answer is A
Choice A reason: This is the correct answer because this question will help the nurse assess the pain level and discomfort of the client with red scaling papules. Red scaling papules are raised skin lesions that are red and covered with scales. They can indicate psoriasis, which is a chronic skin condition that causes inflammation and rapid turnover of skin cells. Psoriasis can cause pain, itching, burning, or stinging sensations in the affected areas. The nurse should ask the client to rate their pain on a numeric or descriptive scale and provide analgesics or topical agents as prescribed.
Choice B reason: This is incorrect because this question will not help the nurse assess the condition of the client with red scaling papules. Red scaling papules are not affected by food intake but by other factors such as stress, infection, injury, or medication. Psoriasis is not an allergic or dietary disorder, but an immune-mediated disorder that causes abnormal skin cell growth. The nurse should ask the client about their medical history, current medications, and triggers or aggravating factors for their psoriasis.
Choice C reason: This is incorrect because this question will not help the nurse assess the condition of the client with red scaling papules. Red scaling papules are not treated with antibiotics but with other medications such as corticosteroids, immunosuppressants, or biologics. Antibiotics are used to treat bacterial infections, which are not the cause of psoriasis. The nurse should ask the client about their treatment regimen, compliance, and effectiveness for their psoriasis.
Choice D reason: This is incorrect because this question will not help the nurse assess the condition of
the client with red scaling papules. Red scaling papules are not related to weekend activities but to chronic skin inflammation and abnormal cell turnover. Psoriasis is not a lifestyle disorder, but a genetic disorder that can be influenced by environmental factors. The nurse should ask the client about their family history, exposure to sun or cold, and stress level for their psoriasis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D"]
Explanation
Choice A Reason: A distended bladder is one of the most common triggers of autonomic dysreflexia, which is a life-threatening condition that occurs in clients with spinal cord injuries above T-6. The bladder becomes overfilled and stimulates the sympathetic nervous system, causing vasoconstriction and hypertension.
Choice B Reason: A severe headache is one of the most common symptoms of autonomic dysreflexia, caused by the increased blood pressure in the brain. The headache may be accompanied by blurred vision, sweating, flushing, or anxiety.
Choice C Reason: An elevated blood pressure is the hallmark sign of autonomic dysreflexia, which can reach dangerously high levels and cause stroke, seizure, or death. The blood pressure may rise up to 300/160 mmHg or higher.
Choice D Reason: Nasal congestion is another possible trigger of autonomic dysreflexia, as it stimulates the nasal mucosa and activates the sympathetic nervous system. Other potential triggers include bowel impaction, skin irritation, tight clothing, or temperature changes.
Correct Answer is D
Explanation
Choice A Reason: This is incorrect because intestinal obstruction is not a common complication of ileostomy surgery. An ileostomy is a surgical opening in the abdomen that connects the end of the small intestine (ileum) to a pouch or bag outside the body. This allows stool to bypass the colon and rectum. Intestinal obstruction can occur if there is a blockage or narrowing in any part of the digestive tract, but it is more likely to affect the colon than the ileum.
Choice B Reason: This is incorrect because folate deficiency is not a common complication of ileostomy surgery. Folate is a vitamin that is essential for DNA synthesis and cell division. Folate is mainly absorbed in the jejunum, which is the middle part of the small intestine. An ileostomy does not affect the jejunum, so it does not interfere with folate absorption.
Choice C Reason: This is incorrect because malabsorption of fat is not a common complication of ileostomy surgery. Fat is digested and absorbed in both the small and large intestine. An ileostomy does not affect fat digestion, but it may reduce fat absorption by decreasing the transit time and surface area of the intestine. However, this is usually not significant enough to cause malabsorption symptoms.
Choice D Reason: This is correct because fluid and electrolyte imbalance is a common complication of ileostomy surgery. Fluid and electrolytes are mainly absorbed in the colon, which is bypassed by an ileostomy. This can result in increased fluid and electrolyte loss through stool, especially sodium and potassium. This can lead to dehydration, hypotension, weakness, cramps, or arrhythmias.
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