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 C

Explanation

Choice A rationale

While monitoring moles is important, teaching a family member how to do so is a secondary action. The client's report of recent changes—color alteration from brown to black and enlargement—are classic "ABCDE" warning signs of melanoma. Immediate professional evaluation is paramount to rule out or confirm malignancy and initiate prompt treatment.

Choice B rationale

While sun exposure is a significant risk factor for skin cancer, asking about past sun exposure does not address the immediate concern of a rapidly changing mole. The priority is to assess the current lesion for malignancy, which requires a healthcare professional's expertise. Historical information is valuable but not the most urgent action.

Choice C rationale

The reported changes in the mole (change in color from brown to black and enlargement) are highly suspicious for melanoma, a serious form of skin cancer. Immediate evaluation by a healthcare provider (HCP), typically a dermatologist, is crucial for timely diagnosis and potential intervention. Delaying evaluation could significantly impact the prognosis if it is malignant.

Choice D rationale

Encouraging the client to self-monitor with a magnifying mirror delays professional assessment of potentially cancerous changes. Self-monitoring is useful for identifying new or changing lesions, but once concerning changes are noted, professional evaluation is required. A magnifying mirror cannot provide a definitive diagnosis or assess deeper tissue involvement. .

A. Compare measured circumferences of each extremity joint. B. Measure the length of each leg and document the findings. C. Instruct client to walk across room and observe the gait. D. Perform passive range of motion and compare the findings.

Correct Answer is B

Explanation

Choice A rationale

While comparing measured circumferences of each extremity joint can provide information on swelling or muscle atrophy, it does not directly assess for asymmetry in leg length, which is the primary concern when legs appear asymmetrical. This measurement is more indicative of fluid accumulation or muscle wasting patterns.

Choice B rationale

Measuring the length of each leg directly quantifies any disparity, providing objective data regarding potential limb length discrepancy. This is crucial for identifying underlying skeletal or muscular issues that could cause asymmetrical appearance and guide appropriate interventions.

Choice C rationale

Observing the client's gait can reveal compensatory mechanisms due to leg length discrepancy, such as a limp or uneven stride. However, gait analysis alone does not definitively confirm or quantify the actual leg length difference, which requires precise measurement.

Choice D rationale

Performing passive range of motion assesses joint mobility and flexibility, but it does not directly measure leg length. While limitations in range of motion might be associated with underlying conditions, they do not specifically address the perceived asymmetry in leg length.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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