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 C

Explanation

Decorticate posturing is a specific type of involuntary abnormal posturing of a person that is a sign of severe damage to the brain¹. In decorticate posture, the arms are bent to hold the hands on the chest and the fists are clenched¹. The hands may each twist inward at the wrists with knuckles facing or touching each other. This is known as the pronation of the hands.

Extension of the extremities is not a characteristic of decorticate posturing. Extension of the extremities is more characteristic of decerebrate posturing, where arms and legs are straight and rigid¹.

External rotation of the lower extremities is not a characteristic of decorticate posturing. In decorticate posture, legs are held out straight¹.

Plantar ﬂexion of the legs is not a characteristic of decorticate posturing. In decorticate posture, legs are held out straight¹.

A. Apply a compression bandage to the client's ankle. B. Apply heat to the client's ankle. C. Encourage the range of motion of the client's foot. D. Elevate the client's foot. E. Check the client's toes for color, temperature, and sensation.

Correct Answer is ["A","D","E"]

Explanation

These are the correct interventions that the nurse should take. Applying a compression bandage to the client's ankle can help reduce swelling and provide support to the injured area. Elevating the client's foot can also help reduce swelling by promoting venous return. Checking the client's toes for color, temperature, and sensation is important to assess for any potential nerve or vascular damage.

Applying heat to the client's ankle is not recommended as it can increase swelling and inﬂammation. Encouraging range of motion of the client's foot is also not recommended as it can cause further injury to the aﬀected area.

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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.)

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Naxlex Comprehensive Predictor Exams

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?

Correct Answer is C

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