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 B
Explanation
Choice A reason: Full thickness skin loss with visible bone indicates a stage 4 pressure injury, not stage 1, which involves intact skin with erythema. Misidentifying this overstates severity, risking inappropriate interventions like surgical debridement instead of preventive measures like repositioning, critical for managing early-stage pressure injuries to prevent progression.
Choice B reason: Stage 1 pressure injury presents as intact skin with non-blanchable localized erythema, often over bony prominences, due to early tissue compression. This finding guides preventive care, like pressure relief and skin protection, to halt progression. Accurate identification ensures timely interventions, reducing risk of deeper tissue damage in at-risk patients.
Choice C reason: Full thickness skin loss with visible adipose tissue describes a stage 3 pressure injury, not stage 1, which has intact skin. Assuming this misdiagnoses severity, leading to unnecessary aggressive treatments like wound dressings, while neglecting early interventions like offloading pressure, critical for preventing worsening of stage 1 injuries.
Choice D reason: Partial-thickness skin loss with red tissue indicates a stage 2 pressure injury, not stage 1, which shows intact skin with erythema. Misidentifying this risks inappropriate wound care, delaying preventive strategies like skin moisturizing or repositioning, essential for managing stage 1 injuries and preventing progression to deeper ulcers.
Correct Answer is B
Explanation
Choice A reason: Percussion involves tapping to assess underlying structures, commonly used for lung or abdominal assessments. In breast assessment, it is not relevant, as it cannot evaluate tissue density or detect masses. Breast examination relies on visual inspection and palpation to identify abnormalities like lumps or skin changes, making percussion inappropriate.
Choice B reason: Inspection is a critical technique in breast assessment, involving visual examination for asymmetry, skin changes, nipple discharge, or dimpling. It precedes palpation to identify visible abnormalities. This method is non-invasive and essential for detecting early signs of breast conditions, such as cancer, aligning with standard clinical protocols for thorough evaluation.
Choice C reason: Doppler ultrasound assesses blood flow, often used in vascular or fetal monitoring, but is not standard for breast assessment. Breast examination uses inspection and palpation, with imaging like mammography for deeper evaluation. Doppler’s role in breast care is limited to specialized diagnostics, not routine physical assessments, making it an incorrect choice.
Choice D reason: Sterile gloves are used for invasive procedures like wound care, not routine breast assessments, which require clean gloves for palpation. Inspection and palpation are primary techniques, and sterile conditions are unnecessary unless performing a biopsy. This choice does not align with standard breast examination practices.
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