The nurse is performing an integumentary system assessment of a patient who has smoked for the last 40 years. The patient has clubbing of the fingernails. What does this finding indicate to the nurse?

The patient has asthma.

The patient has cardiovascular disease.

The patient has emphysema.

The patient has chronic hypoxemia.

Answer and Explanation

The Correct Answer is D

A) The patient has asthma: While asthma can lead to respiratory symptoms and issues, it is not typically associated with clubbing of the fingernails. Asthma primarily affects airway constriction and inflammation, rather than causing the long-term changes in nail morphology seen with clubbing.

B) The patient has cardiovascular disease: Although some cardiovascular conditions can lead to clubbing, it is more commonly associated with chronic lung diseases. Cardiovascular disease might cause other signs or symptoms, but clubbing alone is not a definitive indicator of this condition.

C) The patient has emphysema: Emphysema, a type of chronic obstructive pulmonary disease (COPD), is characterized by the destruction of lung tissue and impaired airflow. While it can contribute to hypoxemia, clubbing is not a common finding specifically associated with emphysema.
D) The patient has chronic hypoxemia: Clubbing of the fingernails is a classic sign of chronic hypoxemia, often resulting from long-term respiratory conditions like COPD, interstitial lung disease, or lung cancer. It indicates a prolonged lack of oxygen in the blood, leading to changes in the nail bed and digit shape. Given the patient's long smoking history, chronic hypoxemia is the most likely explanation for this finding.

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Correct Answer is A

Explanation

A) Increased muscle weakness: Guillain-Barré syndrome is characterized by the rapid onset of muscle weakness, which typically starts in the lower extremities and ascends. The nurse would expect to find varying degrees of muscle weakness as a hallmark symptom, which may progress to involve the upper limbs and respiratory muscles.

B) Pronounced muscle atrophy: While muscle weakness is a significant feature of Guillain-Barré syndrome, pronounced muscle atrophy is not typically seen immediately. Muscle atrophy may occur over time due to disuse but is not a direct initial finding upon assessment.

C) Diminished visual acuity: Visual acuity may not be directly affected in Guillain-Barré syndrome. While some patients may experience ocular symptoms, diminished visual acuity is not a primary feature of the syndrome and would not be expected as a common assessment finding.

D) Impaired cognitive

A. "Please remove all jewellery so that I can conduct a full assessment." B. "I will be touching your skin as part of the process." C. "I will turn the temperature down in the exam room before we begin." "Use this blanket to cover up until we are ready to begin." D. "I will need you to take off your head dress for the entire examination."

Correct Answer is ["A","B","D"]

Explanation

For a thorough assessment of the integumentary system, the nurse should provide the following instructions:

A. "Please remove all jewellery so that I can conduct a full assessment."

This is correct. Jewelry can obstruct the assessment of skin, especially in areas like the neck, chest, and hands, where it may cover or hide skin abnormalities.

B. "I will be touching your skin as part of the process."

This is correct. A thorough integumentary assessment involves palpating the skin to check for texture, moisture, temperature, and other characteristics. It's important for the client to be informed that touch will be involved.

C. "I will turn the temperature down in the exam room before we begin." "Use this blanket to cover up until we are ready to begin."

This is partially correct. The temperature in the exam room should be comfortable, but turning it down may not be necessary. The instruction to cover with a blanket is appropriate to preserve the client's privacy and warmth until the assessment begins.

D. "I will need you to take off your head dress for the entire examination."

This is correct. If the head dress covers the scalp or areas that need to be examined (like the scalp, ears, or face), it should be removed to allow for a full assessment of the integumentary system.

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The nurse is performing an integumentary system assessment of a patient who has smoked for the last 40 years. The patient has clubbing of the fingernails. What does this finding indicate to the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient with a new diagnosis of Guillian-Barré syndrome. What does the nurse expect to find when assessing this patient?

Correct Answer is A

Explanation

The nurse is preparing a client for a thorough assessment of the integumentary system. Which instructions should the nurse provide the client? Select all that apply.

Correct Answer is ["A","B","D"]

Explanation

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