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Exhibits

The nurse reviews the client's data.

Choose the most likely options for the information missing from the sentence by selecting from the lists of options provided.

The client's assessment findings of

and places him at a high risk for multiple other health issues and requires immediate follow up by the nurse.
Answer and Explanation

The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

The client's assessment findings of neuropathy and incontinence place him at a high risk for multiple other health issues and require immediate follow-up by the nurse.

Rationale:

Neuropathy. The client reports neuropathy in both hands and lower legs. Neuropathy leads to decreased sensation, increasing the risk of falls, pressure injuries, and unnoticed wounds, which can become severe due to diabetes-related poor healing. It also contributes to mobility limitations, further affecting the client’s safety and independence.

Incontinence. The client experiences urinary and fecal incontinence due to difficulty moving quickly enough to reach the bathroom. Incontinence increases the risk of skin breakdown, infections, and pressure ulcers, especially since the client has mobility issues and spends prolonged time sitting.

Moist skin. While moist skin may suggest sweating or autonomic dysfunction, it is not as significant a risk factor as neuropathy and incontinence, which directly impact skin integrity and mobility.

Coarse lung sounds. Coarse lung sounds may indicate fluid retention or respiratory congestion, but they are not as immediately concerning as neuropathy and incontinence, which increase the risk for skin damage, infection, and functional decline.


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Related Questions

Correct Answer is C

Explanation

A. Brown, rough, greasy, wart-like papules on the face. These describe seborrheic keratosis, a benign skin growth, which is unrelated to overexposure from PUVA therapy.
B. Requires sunglasses because sunlight hurts eyes. PUVA therapy increases sensitivity to light, and clients are advised to wear sunglasses. However, light sensitivity alone does not indicate overexposure. Severe overexposure could cause ocular damage or photokeratitis, but this symptom alone is not diagnostic of excessive treatment.
C. Tenderness upon palpation and generalized erythema. Overexposure to PUVA therapy can cause phototoxic reactions, including skin tenderness, erythema (similar to a sunburn), and blistering. These signs indicate that the client has received too much ultraviolet A (UVA) exposure, requiring treatment adjustments to prevent further skin damage.
D. Thick skin plaques topped by silvery white scales. These are classic symptoms of psoriasis vulgaris and do not indicate overexposure. In fact, PUVA therapy is used to reduce these plaques, not cause them.

Correct Answer is D

Explanation

A. Offer to also administer a meningococcal vaccine to the client. The meningococcal vaccine is not routinely recommended for older adults unless they are at increased risk (e.g., immunocompromised, asplenic, or in certain outbreak situations). The priority is ensuring the influenza vaccine is appropriate based on the client’s history.
B. Record height, weight, and vital signs before giving the vaccine. Routine height, weight, and vital signs are not necessary before administering an influenza vaccine unless the client has symptoms of illness. The focus should be on vaccination history and contraindications.
C. Ask if the client's influenza exposure was within the last week. Recent exposure to influenza does not contraindicate vaccination. The vaccine is preventive and does not provide immediate protection, so the client should still receive it to help prevent future infection.
D. Review the client's vaccination history in the electronic record. Checking vaccination history ensures the client is receiving the correct vaccine and has not already been vaccinated for the season. This helps prevent unnecessary repeat doses and ensures adherence to recommended immunization schedules.

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