A nurse performs a head-to-toe assessment on a newly admitted client. Data analysis reveals temperature 100.94°F (38.3°C), blood pressure 82/58 mm Hg, 02 saturation 95% on room air, productive cough, lethargy, diaphoresis, WBC 15,000 mm3, hemoglobin 9 g/dl, and hematocrit 29%. Based on the analysis of the data, which of the following client concerns is a priority?

hypoxia

anemia

hypotension

Pneumonia

Answer and Explanation

The Correct Answer is C

A) Hypoxia: Although the client's oxygen saturation is slightly decreased at 95% on room air, it is not critically low. Hypoxia could be a concern, but it is secondary to other more immediate issues, such as hypotension, that might be causing the low oxygen saturation.
B) Anemia: The client’s hemoglobin and hematocrit levels are low, indicating anemia. While anemia is a significant concern, it does not pose an immediate threat compared to hypotension, which can lead to more severe complications if not addressed promptly.
C) Hypotension: The client’s blood pressure is notably low at 82/58 mm Hg. Hypotension can lead to inadequate perfusion of vital organs and may be a result of or contribute to other issues such as sepsis or significant blood loss. Immediate attention to correcting hypotension is crucial to prevent further complications.
D) Pneumonia: The client presents with symptoms suggestive of pneumonia, including a productive cough, fever, and elevated white blood cell count. While pneumonia is a critical condition that requires treatment, addressing hypotension is a more urgent priority as it directly impacts the client's circulatory stability and overall well-being.

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Correct Answer is C

Explanation

A. Bell's palsy: Bell's palsy is characterized by sudden, unilateral facial weakness or paralysis. It does not cause the specific physical signs described in the question, such as a "moon" face, buffalo hump, or velvety discoloration around the neck.

B. Myxedema: Myxedema is associated with severe hypothyroidism and can lead to symptoms such as facial swelling and changes in skin texture, but it does not typically cause a round face, buffalo hump, or velvety neck discoloration. The velvety discoloration around the neck is more characteristic of insulin resistance rather than hypothyroidism.

C. Cushing's syndrome: Cushing's syndrome is caused by excess cortisol and is known for the characteristic signs described. A "moon" face, buffalo hump, and skin changes such as velvety discoloration (often termed "acanthosis nigricans") are hallmark features of this condition. These symptoms align with the body’s response to prolonged high levels of cortisol.

D. Scleroderma: Scleroderma involves skin thickening and tightening, primarily affecting the hands and face, but it does not typically cause a "moon" face, buffalo hump, or velvety neck discoloration. The changes in scleroderma are more related to skin fibrosis and less to the specific physical features listed.

A. angioedema B. actinic cheilitis C. angular cheilitis D. herpes simplex

Correct Answer is D

Explanation

A. Angioedema: Angioedema is characterized by deep swelling of the skin and mucous membranes, often caused by allergic reactions. It usually affects areas like the lips, eyes, or throat but does not typically present with vesicular eruptions.
B. Actinic cheilitis: Actinic cheilitis results from chronic sun exposure leading to changes in the lips' texture and color. It typically presents as dry, scaly patches or discoloration, not vesicular eruptions.
C. Angular cheilitis: Angular cheilitis involves inflammation and cracking at the corners of the mouth, often due to fungal or bacterial infection. It does not typically present with vesicular eruptions.

D. Herpes simplex: Herpes simplex virus commonly causes vesicular eruptions on the lips and surrounding skin, known as cold sores or fever blisters. These eruptions are characteristic of the herpes simplex infection and align with the description of vesicular eruptions observed in the client.

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Naxlex Comprehensive Predictor Exams

When assessing an adult client experiencing diarrhea, the nurse notes a round "moon" face, a buffalo hump at the nape of the neck, and a velvety discoloration around the neck. What is the possible cause of these signs?

Correct Answer is C

Explanation

During the physical examination of the mouth, the nurse identifies vesicular eruptions along the client's lips and surrounding skin. The nurse should document which problem?

Correct Answer is D

Explanation

During an assessment of the cranial nerves, a client reports spontaneously losing balance. The nurse should focus additional assessment on which cranial nerve?

A 16-year-old female client presents with complaints of palpitations. While the nurse is auscultating heart sounds, asking the client to get into a seated position and leaning forward, would help the nurse assess the presence of which of the following?

A nurse is performing a pressure injury risk assessment for a client. Which of the following findings increases the client's risk of a pressure injury?

A client who suffered a stroke 6 months ago and participating in a rehab program is able to actively move the both lower legs against gravity and some resistance. How should the nurse document this finding using the muscle strength grading scale?

A nurse is admitting a client with suspected appendicitis. Identify where the nurse will palpate to assess for pain at McBurney's point. (Selectable areas, or "Hot Spots," are outlined in the artwork below. Select only the outlined area that corresponds to your answer.)

A Community nurse is doing a class teaching measures to prevent peripheral arterial disease. Select all that apply teaching for this topic. (Select All that Apply.)