During the admission assessment, the nurse observes that a client has a limping gait. Which assessment should the nurse complete next?

Ask about pain while bearing weight.

Determine level of consciousness.

Observe for deformity of the spine.

Measure orthostatic blood pressure.

Answer and Explanation

The Correct Answer is A

A.   A limping gait can be a sign of pain or discomfort while walking. By asking about pain while bearing weight, the nurse can get a better understanding of the underlying cause of the limp.
B.   A limping gait is not typically associated with changes in level of consciousness. This assessment is not relevant in this situation.

C.   While a spinal deformity can cause a limping gait, it is not the most likely cause in this case. The nurse should first assess for pain while bearing weight to get a better understanding of the underlying issue.
D.   Orthostatic blood pressure is a measure of blood pressure changes when a person stands up. It is not typically associated with a limping gait and is not relevant in this situation.

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Correct Answer is A

Explanation

A. This finding is most concerning as it could indicate a melanoma, a type of skin cancer that is highly aggressive and potentially fatal. The characteristics of the lesion - large, flat, dark red, irregular - are consistent with a melanoma.
B. Striae are stretch marks, often caused by rapid weight gain or pregnancy. While they can be unsightly, they are generally not a cause for concern.
C. Bluish discoloration of the nailbeds can be a sign of cyanosis, which may indicate a lack of oxygen in the blood. However, it could also be caused by other factors such as cold temperatures or poor circulation. While this finding should be investigated further, it is not as urgent as a large, irregular, dark red area on the neck.
D. These lesions could be xanthelasmas, which are yellow, fatty deposits often associated with high cholesterol levels. While they are not dangerous, they can be a sign of underlying health issues and should be discussed with a healthcare provider.

A. Measure the degree of skin elasticity. B. Palpate the area for warmth and swelling. C. Determine the client's oxygen saturation. D. Observe the appearance of the nailbeds.

Correct Answer is B

Explanation

A. Skin elasticity is assessed by pinching the skin to see how quickly it returns to its normal position, which is often done to evaluate hydration status or the presence of dehydration. While skin elasticity is an important overall assessment of skin health, it is not directly related to the assessment of erythema.
B. Palpating the erythematous area for warmth and swelling is a crucial follow-up assessment. Erythema (redness of the skin) can be a sign of inflammation or infection, and the presence of warmth and swelling can help determine if the area is inflamed or if there might be an underlying infection.
C. Oxygen saturation measurements assess the level of oxygen in the blood, typically using a pulse oximeter. While oxygen saturation is important for assessing overall respiratory and circulatory health, it is not directly related to evaluating the cause or characteristics of erythema. Therefore, this would not be the most relevant follow-up assessment for a red area on the skin.
D. Observing the appearance of the nailbeds can provide information about overall circulation and oxygenation, but it is not directly related to assessing a localized area of erythema on the skin. Changes in the nailbeds can indicate systemic conditions but would not provide specific information about the erythematous area in question.

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During the admission assessment, the nurse observes that a client has a limping gait. Which assessment should the nurse complete next?

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Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is B

Explanation

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