The nurse inspects the client's fingernails. Which differentiating characteristics are observed in this assessment finding?
Longitudinal pigmented bands and red brown linear streaks of recent onset.
Thinned depressed nails with lateral edges tilting up to form a concave profile and proximal subungual fungal infection.
Transverse furrows and nail plate white spots that move forward with nail growth.
A nail base angle greater than 180 degrees and nail plate loosened at the distal-lateral edge, progressing proximally.
None
None
The Correct Answer is D
A. Longitudinal pigmented bands and red-brown linear streaks of recent onset. This description is more indicative of longitudinal melanonychia, which presents as pigmented bands along the length of the nail plate. It's not typically associated with finger clubbing.
B. Thinned, depressed nails with lateral edges tilting up to form a concave profile and proximal subungual fungal infection. This description suggests koilonychia, also known as spoon nails, which are characterized by thin, depressed nails with lateral edges tilting up. The mention of a fungal infection points to a different condition. It doesn't align with finger clubbing.
C. Transverse furrows and nail plate white spots that move forward with nail growth. This description corresponds to Beau's lines and leukonychia, which are not associated with finger clubbing. Beau's lines are transverse furrows or depressions in the nail plate, while leukonychia manifests as white spots or lines.
D. A nail base angle greater than 180 degrees and nail plate loosened at the distal-lateral edge, progressing proximally. This description fits the characteristics of finger clubbing, where there's an increased nail base angle (greater than 180 degrees) and the nail plate is loosened at the distal-lateral edge, progressing proximally. This choice aligns with the assessment finding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Advise the PN that waist circumference measurements are valuable to assess fluid retention but not obesity. Waist circumference is actually a valuable measure for assessing abdominal obesity, which is an important factor in health, independent of BMI. It helps screen for health risks related to overweight and obesity, such as heart disease and type 2 diabetes. Therefore, this option is incorrect.
B. Instruct the PN to measure the client’s waist circumference every 8 hours to assess for changes. Measuring waist circumference does not require frequent assessments like every 8 hours. It’s a simple and inexpensive measurement that provides valuable information about abdominal fat distribution. However, such frequent measurements are unnecessary and impractical for assessing obesity-related risks.
C. Tell the PN that this assessment technique should be performed by the nurse. Waist circumference measurements can be performed by practical nurses (PNs) and other healthcare providers. It’s a straightforward technique that doesn’t require specialized training. Therefore, this option is incorrect.
D. Review the measurement obtained by the PN and compare with ideal measurements for this client. This is the most appropriate action. The nurse should review the PNs measurement of the client’s waist circumference and compare it to established guidelines. Generally, a waist circumference greater than 35 inches for women or greater than 40 inches for men indicates increased risk of obesity-related health problems.
Correct Answer is C
Explanation
A. A bubbling sound heard during inspiration and expiration in the central airways: This description is accurate. Crackles (also called rales) are often heard in conditions like pulmonary edema or pneumonia.
B. A crowing noise heard during inspiration over the trachea: This description refers to stridor, not crackles. Stridor occurs due to upper airway obstruction.
C. Popping, non-musical sounds heard in the lung bases, usually during inspiration: This description is accurate for crackles. They occur due to fluid or secretions in the alveoli.
D. Superficial squeaking or grating sounds heard during inspiration and expiration: This description refers to wheezes, not crackles. Wheezes are associated with narrowed airways.
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