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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.

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B","dropdown-group-3":"C"}

Explanation

Based on the client's history, physical, and laboratory findings, the priority need will be to treat the infection (cellulitis). In addition, the client will need interventions to manage complications, especially deep tissue injury and impaired circulation.

Rationale:

The infection (cellulitis) is the primary concern, as indicated by redness, warmth, swelling, and systemic symptoms like muscle aches. Immediate antibiotic therapy is crucial.

Deep tissue injury is a potential complication due to prolonged inflammation, swelling, and impaired circulation, which can lead to tissue damage.

Impaired circulation is a significant risk in a client with diabetes and peripheral vascular disease, as it can slow healing and increase the likelihood of further complications such as ulcers or necrosis.

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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Naxlex Comprehensive Predictor Exams

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B","dropdown-group-3":"C"}

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

Which test for HIV is used primarily as a confirmatory test rather than a generalized screening test?

Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and to parameters the nurse should monitor to assess the client's progress.

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

Which is the function of the keratinocytes, a type of skin cell?

The nurse is caring for a school age child whose parent reports concern for the child's weight gain and obesity status. Which historical finding should the nurse recognize as potentially contributing to early obesity?

Which client has the highest risk for developing skin cancer?

Exhibits Click to indicate which education instructions the nurse should include to prevent future cellulitis and promote healing when preparing the client for discharge. Each column must have at least one response selected.

Exhibits The client is seen for a 1 week follow up appointment. The nurse is evaluating the response to the treatment for cellulitis. Select the 3 findings consistent with a therapeutic response to interventions.