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Exhibits

The nurse reviews the electronic health record.

Highlight the finding(s) that require the nurse's attention. Select all that apply.

Heart rate 88 beats/minute

Blood pressure 122/72 mm Hg

Temperature 100.5° F (38° C)

Reports of pain with ambulation

Respirations 20 breaths/minute

Left lower leg with erythema, warm, and swollen

Blood glucose 252 mg/dL (13.9 mm

Heart rate 88 beats/minute

Blood pressure 122/72 mm Hg

Temperature 100.5° F (38° C)

Reports of pain with ambulation

Respirations 20 breaths/minute

Left lower leg with erythema, warm, and swollen

Blood glucose 252 mg/dL (13.9 mm

Answer and Explanation

The Correct Answer is ["C","D","F","G"]

Heart rate 88 beats/minute: This is within the normal range (60-100 bpm) and does not require immediate intervention.

Blood pressure 122/72 mm Hg: This is within a normal range and does not indicate an urgent issue.

Temperature 100.5°F (38°C): An elevated temperature suggests a possible infection, such as cellulitis or deep vein thrombosis (DVT), which requires further evaluation.

Reports of pain with ambulation: Pain with walking, especially in a client with peripheral vascular disease and diabetes, may indicate worsening circulation, infection, or DVT.

Respirations 20 breaths/minute: This is within the normal range (12-20 breaths/minute) and does not require immediate intervention.

Left lower leg with erythema, warm, and swollen: These are signs of inflammation or infection, such as cellulitis or a possible DVT, both of which require urgent medical attention.

Blood glucose 252 mg/dL (13.9 mmol/L): Elevated blood glucose can impair wound healing, increase the risk of infection, and contribute to further complications in a client with diabetes.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is {"A":{"answers":"C"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"B"}}

Explanation

Instruct incentive spirometry use every hour (Nonessential): There is no indication of respiratory compromise, so incentive spirometry is not a priority for this client.

Encourage consumption of protein and vitamin C (Indicated): These nutrients support wound healing and immune function, which are important in managing infection and preventing further complications.

Apply thromboembolism deterrent stockings (TED) (Contraindicated): TED stockings may worsen symptoms if the client has cellulitis or a deep vein thrombosis (DVT), as compression can increase pain and impede circulation in an already swollen and inflamed limb.

Use petroleum-based lotion on legs (Contraindicated): Petroleum-based products can trap moisture and create an environment for bacterial growth, which is not suitable for a client with cellulitis or diabetes. Instead, a diabetic-safe moisturizer should be used while avoiding open wounds.

A. It is the main structural component of the dermis which provides strength and elasticity. B. It increases skin elasticity with the aging process. C. It forms the ridges and valleys which provide traction for grasping objects and surfaces. D. It is an extensive network of blood vessels that regulates body temperature.

Correct Answer is A

Explanation

A. It is the main structural component of the dermis which provides strength and elasticity. Collagen is the primary protein in the dermis, responsible for maintaining skin strength, firmness, and elasticity. Sun exposure damages collagen fibers, leading to wrinkles, sagging skin, and premature aging.
B. It increases skin elasticity with the aging process. Collagen production decreases with age, leading to reduced skin elasticity and increased wrinkle formation. Sun damage accelerates this process by breaking down collagen fibers.
C. It forms the ridges and valleys which provide traction for grasping objects and surfaces. Friction ridges (fingerprints) are formed by the dermal papillae, not collagen. They provide grip and are genetically determined.
D. It is an extensive network of blood vessels that regulates body temperature. The dermis contains a network of blood vessels for temperature regulation, but this function is not related to collagen. Instead, collagen provides structural support to the skin.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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.

Correct Answer is {"A":{"answers":"C"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"B"}}

Explanation

The nurse is teaching a health promotion class for adults about the effects of sun exposure on skin. Which statement about the function of collagen is correct?

Correct Answer is A

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?

The public health nurse is evaluating resources in a rural community. Which healthcare resource is most important to the community?

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

A female client was horseback riding when her horse slipped and fell on her leg, crushing but not breaking it, and resulting in a large amount of edema over the crushed area. Which pathophysiological mechanism is responsible for the edema?

After reviewing the history of a group of clients, which client should the nurse identify as having the greatest risk for cancer?

The nurse is talking with a couple at a community health fair who ask how cancerous tumors occur. Which pathophysiological process supports the nurse's reponse about cancer cells developement?

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

Which histologic finding in an affected area of the body suggests the presence of an inflammatory process?