During a client assessment, you noted edema of the left arm. Which of the following subjective data should you collect from the client?
Are you currently or have you recently quit smoking?
Did you have any surgery on your left breast?
Have you gained weight recently?
Do you have any extra nipples?
The Correct Answer is D
Choice A reason: Smoking history is relevant for vascular or lung issues but not directly for unilateral arm edema, which suggests localized causes like lymphedema. Breast surgery history is more pertinent. Assuming smoking is key risks missing lymphatic causes, delaying diagnosis and management of edema in affected patients.
Choice B reason: Left arm edema may indicate lymphedema from breast surgery, like mastectomy, which disrupts lymphatic drainage. Asking about surgery history is critical to identify causes, guiding interventions like compression therapy. This targeted question ensures accurate diagnosis, preventing complications like chronic swelling or infection in patients with post-surgical edema.
Choice C reason: Recent weight gain may cause generalized edema but is less likely for unilateral arm edema, which points to localized issues like post-surgical lymphedema. Assuming weight gain is key risks overlooking specific causes, delaying targeted treatments critical for managing localized edema and improving patient comfort and function.
Choice D reason: Extra nipples (supernumerary nipples) are anatomical variants, unrelated to arm edema, which likely stems from lymphatic or vascular issues. Assuming this is relevant misdirects assessment, risking neglect of surgical history, critical for diagnosing lymphedema and implementing appropriate interventions like lymphatic drainage or compression.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Rebound tenderness in the right lower quadrant, often at McBurney’s point, is a hallmark of appendicitis, indicating peritoneal irritation from an inflamed appendix. This sign, elicited by releasing pressure during palpation, suggests localized inflammation, requiring urgent surgical evaluation to prevent rupture and peritonitis.
Choice B reason: Pancreatitis typically presents with epigastric or left upper quadrant pain, radiating to the back, not right lower quadrant rebound tenderness. It involves pancreatic inflammation, often due to gallstones or alcohol, and is assessed via serum amylase and lipase, not RLQ findings, making this incorrect.
Choice C reason: Cholecystitis causes right upper quadrant pain and tenderness, often with Murphy’s sign, due to gallbladder inflammation. Rebound tenderness in the right lower quadrant is not characteristic, as cholecystitis affects the upper abdomen, making this choice misaligned with the clinical finding.
Choice D reason: Diverticulitis typically causes left lower quadrant pain, as diverticula are common in the sigmoid colon. Right lower quadrant rebound tenderness is not a typical finding, as it suggests appendicitis instead, making this choice incorrect for the described gastrointestinal assessment finding.
Correct Answer is B
Explanation
Choice A reason: Joint deformity is an unexpected musculoskeletal finding, indicating conditions like arthritis or trauma, requiring intervention. Symmetrical movement is normal. Assuming deformity is expected risks neglecting serious issues, delaying treatments like physical therapy or surgery, critical for restoring function and preventing disability in affected patients.
Choice B reason: Symmetrical degrees of movement are expected in musculoskeletal assessments, indicating normal joint function and muscle strength. Asymmetry, deformity, or limited movement are abnormal. Recognizing this ensures focus on true abnormalities, guiding accurate diagnosis and interventions for musculoskeletal issues, critical for maintaining mobility and function in patients.
Choice C reason: Limited ability to complete maneuvers is an unexpected finding, suggesting joint stiffness, pain, or weakness, possibly from arthritis or injury. Symmetrical movement is normal. Assuming this is expected risks missing treatable conditions, delaying interventions like therapy or medication, critical for improving musculoskeletal function and patient quality of life.
Choice D reason: Differences in movement between right and left sides are unexpected, indicating asymmetry from conditions like stroke or injury. Symmetrical movement is normal. Assuming asymmetry is expected risks overlooking neurological or musculoskeletal issues, delaying diagnosis and rehabilitation, critical for restoring balanced function in patients with movement disparities.
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