A nurse is collecting data from a client who has an exacerbation of gout. Which of the following findings should the nurse expect? (Select all that apply.)

Tight skin

Edema

Tophi

Symmetrical joint pain

Erythema

Answer and Explanation

Correct Answer : B,C,E

A nurse collecting data from a client who has an exacerbation of gout should expect to find edema, tophi, and erythema. Gout is a type of arthritis that occurs when urate crystals accumulate in the joints, causing inﬂammation and intense pain. Edema (swelling) is a common symptom of gout⁴. Tophi are deposits of urate crystals that can form under the skin in people with chronic gout³. Erythema (redness) is another common symptom of gout⁴.

a. Tight skin is not a common symptom of gout.

d. Symmetrical joint pain is not a common symptom of gout, as it usually affects only one joint at a time.

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Correct Answer is B

Explanation

Checking capillary refill in the aﬀected extremity every 4 hr is an important intervention for a nurse to include in the plan of care for an older adult client who is 4 hr postoperative following an open reduction and internal fixation of a fractured femur. This helps to monitor the blood flow to the aﬀected extremity and ensure that it is adequate.

a. Maintaining the client on bed rest for 72 hr after surgery is not necessarily required for a patient who has undergone an open reduction and internal fixation of a fractured femur. The patient's mobility should be determined by their individual needs and the surgeon's instructions.

c. Restricting oral ﬂuid intake to 1,000 ml per day is not necessary for a patient who has undergone an open reduction and internal fixation of a fractured femur. The patient's ﬂuid intake should be determined by their individual needs and any medical conditions they may have.

d. Removing antiembolic stockings once each day to examine skin integrity is not necessarily required for a patient who has undergone an open reduction and internal fixation of a fractured femur. The use of antiembolic stockings and their removal should be determined by the patient's individual needs and the surgeon's instructions.

A. Sudden sleepiness B. Headache C. Diplopia D. Slight ataxia

Correct Answer is A

Explanation

The nurse should report sudden sleepiness to the provider immediately if the client has a traumatic head injury. Sudden sleepiness can indicate an increase in intracranial pressure, which can be a life-threatening complication of a head injury.

Headache, diplopia, and slight ataxia are also important findings that the nurse should report to the provider. However, these findings are not as urgent as sudden sleepiness. Headache can be a common symptom following a head injury. Diplopia is double vision and can indicate cranial nerve damage. Slight ataxia is unsteadiness or lack of coordination and can indicate neurological damage.

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A nurse is collecting data from a client who has an exacerbation of gout. Which of the following findings should the nurse expect? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the plan of care for an older adult client who is 4 hr postoperative following an open reduction and internal fixation of a fractured femur. Which of the following interventions should the nurse include in the plan of care?

Correct Answer is B

Explanation

A nurse is collecting data from a client who has a traumatic head injury. Which of the following findings should the nurse report to the provider immediately?

Correct Answer is A

Explanation

A nurse is assisting with the care of a newly-admitted client who has acute osteomyelitis. Which of the following interventions is the priority for the nurse to implement?

A nurse is reinforcing teaching with a client who has an ankle sprain. Which of the following instructions should the nurse include?

A nurse is collecting data from a client who has increased intracranial pressure and is informed by the charge nurse that the client demonstrates decorticate posturing. Which of the following findings should the nurse expect to observe?

A nurse is discussing skeletal and skin traction with a newly licensed nurse. Which of the following statements should the nurse identify as an indication that the newly licensed nurse understands these therapies?

While collecting data from a client who has a cast on his right leg, a nurse locates an area on the cast that feels warm to the touch. Which of the following findings should the nurse identify as a complication to the client's condition?

A nurse contributes to the plan of care for a client to achieve the outcome of functional healing of a fracture. Which of the following nursing interventions is the highest priority to assist in meeting this outcome?

A nurse is collecting data from a client who has a score of 8 using the Glasgow Coma Scale. Which of the following findings should the nurse expect?