A young adult client is brought to the emergency department reporting a headache. The client has bruises around the face and on the upper arms. The nurse suspects the client is the victim of physical abuse. In which order should the nurse implement these interventions? (Arrange the nursing actions with the highest priority first, on top, and lowest priority last, on bottom.)

Provide a safety plan to prevent further violence.

Inspect head for trauma.

Evaluate range of motion of all joints.

Perform a neurological exam.

Answer and Explanation

The Correct Answer is B,D,C,A

Inspect head for trauma. Head injuries can be life-threatening, so the nurse must first assess for signs of skull fractures, concussions, or intracranial bleeding that could explain the headache.
Perform a neurological exam. If head trauma is suspected, a neurological exam is essential to assess for altered mental status, coordination deficits, or signs of increased intracranial pressure.
Evaluate range of motion of all joints. After ruling out life-threatening conditions, the nurse should assess for musculoskeletal injuries, fractures, or soft tissue damage from physical abuse.
Provide a safety plan to prevent further violence. Once the client is medically stable, the nurse should provide resources, assess risk for further harm, and develop a safety plan to prevent future abuse.

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Correct Answer is []

Explanation

Potential Condition:
Diabetic neuropathy – The client has a history of type 1 diabetes, and her elevated Hemoglobin A1C (8.2%) suggests poor blood glucose control, which increases the risk of diabetic neuropathy.

Actions to Take:
Perform a sensory test on both feet – Diabetic neuropathy can cause loss of sensation in the feet. A sensory test helps assess nerve function and detect early signs of neuropathy.
Instruct the client to change to clean, dry socks – Proper foot care is crucial for preventing infections and complications in clients with diabetes. Keeping feet dry reduces the risk of skin breakdown and infections.

Parameters to Monitor:
Pedal pulses – Poor circulation is a common complication of diabetes and neuropathy. Monitoring pedal pulses helps assess blood flow to the feet.
Blood glucose – Tight glucose control is essential for preventing the progression of diabetic neuropathy. Monitoring blood glucose levels helps guide management and treatment adjustments.

A. Hyperpigmented areas that vary in form and color and are slightly elevated from the skin. B. Small, skin-colored, pedunculated papules in areas of skin folds and on other areas as skin tags. C. Sharply demarcated silvery scaling plaques with underlying redness on the elbows and knees. D. Hyperactive sebaceous areas forming comedones, papules, pustules on the face, neck, and upper back.

Correct Answer is D

Explanation

A. Hyperpigmented areas that vary in form and color and are slightly elevated from the skin
These findings are characteristic of skin conditions such as lentigines or melanocytic nevi rather than acne vulgaris. Acne typically presents with inflammatory and non-inflammatory lesions, not hyperpigmented patches of varying color and elevation.
B. Small, skin-colored, pedunculated papules in areas of skin folds and on other areas as skin tags
Skin tags, also known as acrochordons, are benign growths that develop in areas of skin friction. They are not associated with acne vulgaris, which primarily affects the sebaceous glands and hair follicles.
C. Sharply demarcated silvery scaling plaques with underlying redness on the elbows and knees
These findings are typical of psoriasis, a chronic autoimmune skin condition. Acne vulgaris does not present with silvery scaling plaques or well-defined erythematous lesions in these locations.
D. Hyperactive sebaceous areas forming comedones, papules, pustules on the face, neck, and upper back
Acne vulgaris results from increased sebum production, follicular hyperkeratinization, bacterial overgrowth, and inflammation. It commonly presents with comedones (blackheads and whiteheads), inflammatory papules, pustules, and sometimes nodules, predominantly affecting the face, neck, chest, and upper back.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and to parameters the nurse should monitor to assess the client's progress.

Correct Answer is []

Explanation

The nurse is caring for a young adult who reports uncontrolled acne vulgaris. Which pathological findings should the nurse observe on inspection of skin areas commonly affected in acne vulgaris?

Correct Answer is D

Explanation

The nurse should recognize which response is the immune system's reaction to a source of inflammation?

Exhibits For each potential nursing action, click to indicate whether the action is indicated, contraindicated, or nonessential for this client's plan of care. Each row must have only one option selected.

Exhibits Click to indicate which education instructions the nurse should include to prevent future cellulitis and promote healing when preparing the client for discharge. Each column must have at least one response selected.

The nurse is visiting an older adult client who is homebound. Which finding about the client's nutritional status requires additional follow- up?

The nurse is caring for a client who is receiving teletherapy radiation for a malignant tumor. Which instructions regarding skin care of the portal site should the nurse provide?

Exhibits Choose the most likely options for the information missing from the statement by selecting from the lists of options provided. The client is eating a diet with dropdownof fat, which indicates that the clientdropdown