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 D

Explanation

A. Vital sign abnormalities can provide critical information about the client's overall condition and help determine if there is an acute or chronic issue that needs to be addressed. While important, this assessment might not provide specific details about the cause of the productive cough.
B. Peripheral edema is often related to cardiovascular or renal issues and might not be directly related to the cause of a productive cough. While edema can provide information about fluid balance and possible heart failure, it does not directly address the specific characteristics or causes of a cough.
C. A white blood cell count can help determine if there is an underlying infection or inflammatory process. Elevated WBC levels might indicate an infection, which could be a cause of the productive cough. This test is useful for diagnosing conditions like pneumonia or bronchitis but is not as immediately relevant as assessing the sputum characteristics in understanding the nature of the cough.
D. The characteristics of sputum (color, consistency, presence of blood, etc.) can provide valuable information about the cause of the productive cough. For instance, yellow or green sputum might suggest a bacterial infection, while clear sputum could be associated with viral infections or allergies.

A. There is a history of COPD. B. The client has a collapsed lung C. The client's lungs are functioning normally. D. A chronic lung infection is the likely condition.

Correct Answer is B

Explanation

A. Chronic Obstructive Pulmonary Disease (COPD) can lead to decreased lung function and abnormalities in lung expansion. However, COPD typically results in a more generalized decrease in lung expansion and breath sounds, rather than pronounced unilateral inequality. While COPD can cause irregularities in lung expansion, it is less likely to cause significant unilateral differences in lung expansion.
B. Unequal lung expansion is a key sign of a collapsed lung, or pneumothorax. When a lung collapses, the affected side will show reduced or absent expansion compared to the unaffected side. This is because the collapsed lung cannot expand properly during inhalation, leading to noticeable differences in breath sounds and lung movement on physical examination.
C. If the client's lungs were functioning normally, one would expect to observe symmetrical lung expansion. Unequal lung expansion is not a normal finding and usually indicates some form of pathology or abnormality in the lung or thoracic cavity. Normal lung function should result in even expansion of both lungs.
D. Chronic lung infections, such as tuberculosis or severe pneumonia, might cause abnormalities in lung sounds or localized lung issues, but they are less likely to cause pronounced unilateral differences in lung expansion. While they can affect lung function, they typically do not cause the same degree of unilateral expansion issues as a pneumothorax would.

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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

While assessing a client, the nurse observes that the client has a frequent productive cough. What follow-up assessment should the nurse evaluate first?

Correct Answer is D

Explanation

When assessing an adult client, the nurse notes that the client has unequal lung expansion. Which conclusion regarding this finding is most likely to be accurate?

Correct Answer is B

Explanation

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