The nurse assesses that a client has nailbed clubbing.
Which additional information is consistent with this finding?

3+ peripheral dependent edema.

Oxygen saturation of 85%.

Absent deep tendon reflexes.

Capillary refill less than 3 seconds.

Answer and Explanation

The Correct Answer is B

Choice A rationale

3+ peripheral dependent edema indicates significant fluid retention in the extremities, often associated with cardiovascular or renal dysfunction. While it reflects systemic issues, it is not directly linked to nailbed clubbing, which primarily arises from chronic tissue hypoxemia affecting distal capillaries.

Choice B rationale

Nailbed clubbing is a clinical sign strongly associated with chronic hypoxemia, where oxygen saturation levels are persistently low. An oxygen saturation of 85% indicates significant hypoxemia (normal range 95-100%), which can lead to the compensatory vascular changes and connective tissue proliferation observed in clubbing.

Choice C rationale

Absent deep tendon reflexes suggest neurological impairment, often related to peripheral neuropathy or spinal cord issues. This finding is unrelated to nailbed clubbing, which is a manifestation of prolonged systemic hypoxia, not nerve damage or reflex arcs.

Choice D rationale

Capillary refill less than 3 seconds indicates adequate peripheral perfusion and is considered a normal finding (normal range <3 seconds). This contrasts with nailbed clubbing, which is indicative of impaired oxygenation and not typically associated with normal capillary refill times.

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Correct Answer is D

Explanation

Choice A rationale

Ecchymosis refers to a bruise, which is a larger area of discoloration caused by blood extravasation into subcutaneous tissue, typically greater than 1 cm in diameter. The description of "round, flat, pinpoint, red spots" does not align with the characteristics of an ecchymosis.

Choice B rationale

A vesicle is a small, fluid-filled blister, usually less than 1 cm in diameter, such as those seen in chickenpox or herpes. The described spots are flat and red, not elevated or fluid-filled, thus not consistent with a vesicle.

Choice C rationale

A hematoma is a localized collection of clotted blood outside blood vessels, often forming a palpable mass. The described lesions are pinpoint and flat, indicating a superficial bleed that does not form a significant mass, differentiating it from a hematoma.

Choice D rationale

Petechiae are small, pinpoint (1-2 mm), non-blanching red or purple spots on the skin or mucous membranes caused by extravasation of small amounts of blood from capillaries. The description of "round, flat, pinpoint, red spots" perfectly matches the clinical presentation of petechiae.

A. Perform a head-to-toe physical assessment. B. Prepare to collect a vaginal specimen for Papanicolaou smear. C. Collect information about the client's activities since surgery. D. Conduct a comprehensive review of systems.

Correct Answer is C

Explanation

Choice A rationale

While a head-to-toe physical assessment is comprehensive, a focused approach is more appropriate for a routine postsurgical evaluation six weeks after a hysterectomy. The primary concern is the client's recovery and any specific issues related to the surgery, making a broad assessment less efficient for this purpose.

Choice B rationale

A Papanicolaou smear is a screening test for cervical cancer, which is not indicated six weeks after a hysterectomy where the cervix has been removed. This procedure is irrelevant to a routine postsurgical evaluation for recovery from the surgical intervention itself.

Choice C rationale

Collecting information about the client's activities since surgery allows the nurse to assess healing, mobility, pain management, and any complications related to the hysterectomy. This targeted approach efficiently gathers relevant data concerning the client's recovery and functional status.

Choice D rationale

A comprehensive review of systems, while thorough, is a broad approach that might not be the most efficient for a routine postsurgical evaluation. Focusing on activities and specific postsurgical concerns provides more pertinent information for assessing recovery and identifying potential complications related to the hysterectomy.

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The nurse assesses that a client has nailbed clubbing. Which additional information is consistent with this finding?

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Naxlex Comprehensive Predictor Exams

The nurse is performing a head-to-toe physical examination on a known victim of intimate partner violence. The visual exam reveals several round, flat, pinpoint, red spots. How should the nurse document this finding?

Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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The nurse assesses that a client has nailbed clubbing.
Which additional information is consistent with this finding?