The nurse's inspection of a client's extremities reveals a deep, circular, painful wound on the client's great toe. What should the nurse suspect as the etiology of the client's wound?

Blood is returning from the client's toe more slowly than normal.

There is a disruption in osmotic pressure in the client's extremities.

There is a blockage or infection in the client's lymphatic system.

The client's toe is receiving an inadequate supply of blood.

Answer and Explanation

The Correct Answer is D

Choice A reason: Slow venous return causes edema, not deep, painful wounds. This venous issue lacks the arterial insufficiency link to tissue necrosis, misaligning with the circular ulcer’s ischemic profile, which requires oxygen delivery, not just drainage, here fully.

Choice B reason: Osmotic pressure disruption affects fluid balance, not localized wounds. This systemic issue doesn’t explain a toe ulcer’s depth and pain, missing the vascular supply deficit driving tissue breakdown in this specific extremity finding entirely and clearly.

Choice C reason: Lymphatic blockage or infection causes swelling or lymphangitis, not deep, circular wounds. This lacks the ischemic etiology of toe ulcers, which stem from arterial insufficiency, not lymphatic dysfunction, distinguishing it from the observed pathology here fully.

Choice D reason: Inadequate arterial blood supply, as in peripheral artery disease, causes deep, painful toe ulcers due to tissue ischemia. Poor oxygen delivery leads to necrosis, matching the wound’s characteristics, making this the most likely etiology accurately and precisely.

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Correct Answer is B

Explanation

Choice A reason: Small/moderate brown cerumen is normal, not a sign of infection, which shows pus or redness. Assessing further wastes effort, as cerumen protects the canal, and no symptoms like pain or hearing loss suggest pathology here requiring investigation.

Choice B reason: Documenting small/moderate brown cerumen as normal is correct, as it’s a protective earwax variant. Absent symptoms, this finding needs no intervention, aligning with standard practice to record typical ear assessments without escalating care unnecessarily in this case.

Choice C reason: Teaching hygiene isn’t needed for normal cerumen levels, which self-regulate. Excessive cleaning risks impaction or injury, and with no blockage or symptoms, this action overcomplicates a routine finding better left to natural ear processes here.

Choice D reason: Noting for ear drops assumes intervention for a non-issue. Normal brown cerumen doesn’t require softening or removal unless symptomatic, making this step premature and unnecessary, diverging from evidence-based care for typical ear findings fully.

A. Loss of tactile sensation B. Difficulty speaking C. Blurred vision D. Inability to hear high-pitched sounds

Correct Answer is B

Explanation

Choice A reason: Loss of tactile sensation ties to parietal lobe damage, not frontal. A frontal contusion affects executive function and speech, not sensory processing, making this finding less likely given the injury’s location in this trauma scenario fully.
Choice B reason: Difficulty speaking, like Broca’s aphasia, is common with frontal lobe contusions, as this area houses speech production centers. Post-accident, this aligns with damage to motor speech pathways, making it the most probable finding here accurately.
Choice C reason: Blurred vision relates to occipital or optic nerve injury, not frontal lobe. A contusion here impacts cognition or speech, not visual processing, rendering this less expected than speech issues in this head injury context entirely.
Choice D reason: Inability to hear high-pitched sounds involves cranial nerve VIII or temporal lobe, not frontal. This contusion affects behavior and speech, not auditory function, excluding this as a primary finding in this frontal damage case fully.

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The nurse's inspection of a client's extremities reveals a deep, circular, painful wound on the client's great toe. What should the nurse suspect as the etiology of the client's wound?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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