When assessing a client's skin, which finding should the nurse report to the healthcare provider?

Large, flat, dark red irregular area on the neck.

Multiple silver striae on the abdomen.

Bluish discoloration of the nailbeds.

Multiple yellow lesions with a grainy surface.

Answer and Explanation

The Correct Answer is A

A.   This finding is most concerning as it could indicate a melanoma, a type of skin cancer that is highly aggressive and potentially fatal. The characteristics of the lesion - large, flat, dark red, irregular - are consistent with a melanoma.
B.   Striae are stretch marks, often caused by rapid weight gain or pregnancy. While they can be unsightly, they are generally not a cause for concern.
C.   Bluish discoloration of the nailbeds can be a sign of cyanosis, which may indicate a lack of oxygen in the blood. However, it could also be caused by other factors such as cold temperatures or poor circulation. While this finding should be investigated further, it is not as urgent as a large, irregular, dark red area on the neck.
D.   These lesions could be xanthelasmas, which are yellow, fatty deposits often associated with high cholesterol levels. While they are not dangerous, they can be a sign of underlying health issues and should be discussed with a healthcare provider.

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Correct Answer is A

Explanation

A. Pain radiating to the neck, jaw, or medial side of the left arm is a classic symptom of an acute myocardial infarction (AMI). This type of referred pain occurs because the heart's pain signals are often perceived in other areas of the body. This finding is a strong indicator of AMI and is consistent with the typical presentation of myocardial infarction.
B. Pain in the anterior thorax that radiates between the scapulae can be associated with various conditions, including myocardial infarction, but it is less specific than pain radiating to the neck, jaw, or arm. While this type of pain can occur in AMI, it is not as distinctive as the classic left arm pain and may also be seen in conditions like angina or musculoskeletal issues.
C. Localized sternal border pain that worsens with palpation is more indicative of a musculoskeletal issue, such as costochondritis, rather than an acute myocardial infarction. AMI typically presents with diffuse chest pain that is not localized or worsened by palpation.
D. Chest pain that worsens with chest movement, such as deep breathing or coughing, is more characteristic of pleuritic pain or musculoskeletal pain rather than an acute myocardial infarction. In AMI, the pain is generally persistent and not influenced by respiratory movements.

A. Observe chest and upper neck for a rash. B. Evaluate for a loss of peripheral vision. C. Assess deep tendon reflexes. D. Perform a hearing test.

Correct Answer is D

Explanation

A. Observing the chest and upper neck for a rash is not directly relevant to assessing tinnitus. Tinnitus is an auditory condition, and a rash in these areas would not typically provide information about the presence or effects of tinnitus. This option is not suitable for evaluating tinnitus.
B. Evaluating for a loss of peripheral vision is related to visual assessments rather than auditory conditions. Peripheral vision loss does not provide direct information about tinnitus or its effects. This option is not relevant to assessing the impact of tinnitus.
C. Assessing deep tendon reflexes is a neurological examination that helps evaluate the functioning of the nervous system but does not provide information about tinnitus. Tinnitus is related to auditory perception and not directly assessed through reflexes.
D. Performing a hearing test is directly relevant to evaluating tinnitus. Tinnitus often accompanies hearing loss or auditory dysfunction. A hearing test can help determine if there is a hearing impairment or other auditory issues associated with tinnitus.

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When assessing a client's skin, which finding should the nurse report to the healthcare provider?

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Naxlex Comprehensive Predictor Exams

The nurse assesses a male client who is brought to the emergency department (ED) by his family who believes he is having a heart attack. Which finding is the best indicator that a client is experiencing an acute myocardial infarction (AMI)?

Correct Answer is A

Explanation

In reading a client's record, the nurse notes that the client is experiencing tinnitus. Which assessment provides the nurse with the information needed to evaluate the effects of this condition?

Correct Answer is D

Explanation

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