A nurse is performing an assessment on the fingers and toes of a patient.
What finding is consistent with clubbing?
Decreased angle between the cuticles and the nails.
Upward curving of the nails.
Blue nails.
Angle of nails > 160 degrees.
The Correct Answer is D
Choice A rationale
A decreased angle between the cuticles and the nails is not indicative of clubbing. In fact, it is often associated with healthy nails. Clubbing is recognized by changes that increase the angle between the nail bed and the cuticle.
Choice B rationale
An upward curving of the nails, known as koilonychia or spoon nails, is not characteristic of clubbing but is often associated with iron-deficiency anemia. Hence, this answer is incorrect for clubbing.
Choice C rationale
Blue nails indicate cyanosis, which is related to a lack of oxygen in the blood. This is distinct from clubbing, which is more about the shape and angle of the nails rather than their color.
Choice D rationale
Clubbing is recognized by an increase in the angle between the nail bed and the cuticle, often greater than 160 degrees. This is a hallmark feature and the correct indicator of clubbing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
The Romberg test evaluates equilibrium by having the client stand with feet together and eyes closed, observing for swaying or imbalance. It assesses the function of the vestibular system, proprioception, and cerebellar function, making it the most appropriate test for assessing dizziness and equilibrium.
Choice B rationale
The Weber test involves placing a tuning fork on the forehead to evaluate sound lateralization. It assesses hearing loss but not equilibrium, making it less suitable for dizziness assessment.
Choice C rationale
The Rinne test compares air and bone conduction of sound using a tuning fork. While useful for diagnosing conductive hearing loss, it does not assess equilibrium, making it inappropriate for evaluating dizziness.
Choice D rationale
The cover test evaluates eye alignment and muscle function by having the client cover one eye and observe the uncovered eye for movement. It assesses ocular motility but not equilibrium, making it unsuitable for dizziness assessment.
Correct Answer is A
Explanation
Choice A rationale
"C" in the ABCDE criteria for assessing skin lesions stands for Color. This criterion refers to the variations in the color of the lesion, which could include shades of black, brown, tan, or even white, red, or blue. Uneven or multiple colors within a single lesion can be a warning sign of melanoma, a type of skin cancer. Regularly checking the color of moles or spots on the skin is crucial for early detection of potential malignancies.
Choice B rationale
Characteristics are not part of the ABCDE criteria. The ABCDE criteria specifically stand for Asymmetry, Border, Color, Diameter, and Evolving. These criteria are used by healthcare professionals to identify suspicious skin lesions that may need further evaluation or biopsy to rule out skin cancer. Focusing on these specific aspects helps in early detection and treatment of malignant skin conditions.
Choice C rationale
Crepitus is a term used to describe a crackling or grating sound or sensation, typically associated with bones or joints, and is not related to skin lesion assessment. Crepitus can be felt or heard in conditions such as arthritis, where the cartilage in the joints has worn away, causing bones to rub against each other. It is unrelated to the ABCDE criteria for skin lesions.
Choice D rationale
Coping methods are strategies used by individuals to manage stress, emotions, or adverse situations and have no relevance to the ABCDE criteria for skin lesions. Coping methods can include techniques like exercise, meditation, or talking to a therapist, but they do not pertain to the physical examination of skin lesions for signs of cancer.
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