A nurse is caring for a client with a new skin inflammation on the chest. Which of the following is an important assessment question to ask the client?
How many people live in your home?
Did you have a recent exposure to Irritants?
Is nausea associated with your rash7
What is your body mass index?
The Correct Answer is B
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A. How many people live in your home?
This question pertains to social and environmental factors but is not directly related to assessing skin inflammation on the chest. While social factors can impact overall health, such as stress levels or exposure to infectious agents, the number of people living in the client's home is unlikely to be directly related to a new skin inflammation unless there are specific circumstances, such as sharing personal care products or close contact with others who have similar skin issues.
B. Did you have a recent exposure to irritants?
This question is highly relevant to assessing a new skin inflammation on the chest. Exposure to irritants or allergens can trigger or worsen skin conditions, such as contact dermatitis or allergic reactions. By asking about recent exposure to potential irritants like new detergents, soaps, fabrics, chemicals, or environmental factors, the nurse can gather important information to identify possible triggers for the skin inflammation.
C. Is nausea associated with your rash?
Nausea is typically not directly associated with a skin rash or inflammation unless there is a systemic condition or allergic reaction causing both symptoms. While it's important to assess for any systemic signs or symptoms that may be related to the skin condition, such as fever or malaise, specifically asking about nausea may not provide relevant information about the skin inflammation on the chest.
D. What is your body mass index?
Body mass index (BMI) is a measure of body weight relative to height and is not directly related to assessing a new skin inflammation on the chest. While obesity or changes in body weight can sometimes contribute to skin issues, such as friction-related dermatitis or hormonal changes affecting skin health, BMI alone is not a primary assessment parameter for localized skin conditions unless there are specific concerns related to weight-related skin problems.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A.Prone positioning and postural drainage are typically not appropriate interventions for a client 1 day postoperative following an open thoracotomy, as this could place stress on the incision site and cause discomfort or injury.
B.High-Fowler's position facilitates lung expansion, which can improve ventilation and oxygenation. Encouraging the use of an incentive spirometer and promoting coughing helps clear secretions and expand the lungs, addressing the mild respiratory acidosis indicated by the ABG results (pH 7.31 and PaCO2 50 mm Hg).
C.Increasing oxygen to 70% is not appropriate, as the PaO2 level is within normal limits (93 mm Hg). The client's issue appears to be related more to ventilation (indicated by the elevated PaCO2) rather than oxygenation, so additional oxygen would not address the underlying cause and could lead to oxygen toxicity if used long-term.
D.A nonrebreather mask delivers a high concentration of oxygen, which is not necessary in this case since the client’s PaO2 is already adequate. The primary issue is not a lack of oxygen but rather the retention of CO2, so promoting ventilation and lung expansion through positioning and respiratory exercises is more appropriate.
Correct Answer is D
Explanation
A. Diabetic ketoacidosis (DKA) in a person with emphysema:
In DKA, there is typically metabolic acidosis due to the accumulation of ketones in the blood, leading to a decrease in pH. However, the respiratory compensation mechanism in DKA usually results in a decreased PaCO2 (respiratory alkalosis) rather than an elevated PaCO2 as seen in the blood gas values provided. Additionally, emphysema is associated with chronic respiratory acidosis, not respiratory alkalosis as indicated by the elevated PaCO2.
B. Diarrhea for 36 hours in an older, frail woman:
Prolonged diarrhea can lead to metabolic acidosis due to the loss of bicarbonate through the gastrointestinal tract. The pH of 7.12 and the decreased HCO3- (22 mEq/L) suggest metabolic acidosis. However, the elevated PaCO2 (respiratory acidosis) is not consistent with pure metabolic acidosis caused by diarrhea. Respiratory acidosis typically occurs due to hypoventilation or respiratory dysfunction.
C. Anxiety-induced hyperventilation in an adolescent:
Anxiety-induced hyperventilation can lead to respiratory alkalosis due to excessive blowing off of CO2, resulting in a decrease in PaCO2. The pH of 7.12 is consistent with acidosis, but the elevated PaCO2 contradicts respiratory alkalosis. Anxiety-induced hyperventilation would typically result in a higher pH and lower PaCO2.
D. Bronchial obstruction related to aspiration of a hot dog:
A bronchial obstruction causing inadequate ventilation can lead to respiratory acidosis due to CO2 retention. The pH of 7.12 and the elevated PaCO2 (65 mm Hg) indicate respiratory acidosis. This situation is consistent with the blood gas values provided.
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