When assessing a client's skin, which finding should the nurse report to the healthcare provider?
Multiple yellow lesions with a grainy surface.
Large, flat, dark red irregular area on the neck.
Bluish discoloration of the nail beds.
Multiple silver striae on the abdomen
The Correct Answer is C
A. Multiple yellow lesions with a grainy surface. These could indicate xanthomas, which are associated with lipid disorders and may warrant further investigation and treatment.
B. Large, flat, dark red irregular area on the neck. This could be a port-wine stain, which is typically a congenital condition and may not require immediate medical intervention unless associated with other symptoms.
C. Bluish discoloration of the nail beds. This indicates cyanosis, which can be a sign of hypoxia or cardiovascular issues. It requires prompt evaluation by a healthcare provider to determine the underlying cause and necessary interventions.
D. Multiple silver striae on the abdomen. Striae, or stretch marks, are usually benign and often result from rapid weight changes or hormonal variations. They typically do not require immediate medical attention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A: Ask when the adolescent was last seen in the clinic. This option might help confirm the identity and recent activity of the patient, but it does not address the primary issue of confidentiality and privacy regarding the adolescent's medical information. Simply asking when the adolescent was last seen does not change the legal requirement to obtain consent from the patient who is now an adult.
B: Explain that the information cannot be released without the 18-year-old's permission. This is the most appropriate response. Once an individual turn 18, they are legally an adult and their health information is protected under the Health Insurance Portability and Accountability Act (HIPAA) in the United States, or similar privacy laws in other countries. Without explicit permission from the 18-year-old patient, the nurse cannot legally release medical information to anyone else, including parents.
C: Tell the mother to have the teenager call the clinic. While this response encourages the teenager to take responsibility for their own healthcare, it does not address the immediate concern of the mother inquiring about the results. It shifts the responsibility to the adolescent but doesn't explain why the mother cannot be given the information. It's a partial solution but lacks clarity on the confidentiality issue.
D: Since the serum samples were drawn last week, provide the mother with the findings. This option is inappropriate and violates HIPAA regulations. Regardless of when the serum samples were drawn, the patient is now legally an adult and the information cannot be shared without their explicit consent. Providing the mother with the findings would be a breach of the adolescent's privacy and legal rights.
Correct Answer is D
Explanation
A: Primary source of water. This assessment might be relevant if there is a concern about lead exposure or other contaminants in the water, which can contribute to anemia. Therefore, while important in certain contexts, it is not the most immediate assessment for these specific clinical manifestations.
B: Standard household income. Household income can influence access to nutritious food and overall health. Lower income can lead to food insecurity, poor diet quality, and subsequently, anemia and lower BMI due to inadequate nutrient intake. This can be an indirect but important factor to consider. However, it does not directly assess the child’s dietary intake or specific nutritional deficiencies.
C: Family history of eating disorders. Family history of eating disorders might provide insights into potential genetic or environmental predispositions to eating disorders. However, eating disorders are more commonly associated with adolescents and adults rather than school-age children.
D: Average daily intake of meals. This is the most directly relevant assessment. Analyzing the child's average daily intake of meals can provide immediate insights into potential nutritional deficiencies that might explain both the low hemoglobin level (anemia) and low BMI. Poor dietary intake, particularly of iron-rich foods, can lead to iron-deficiency anemia and inadequate caloric intake, affecting BMI. This assessment helps identify specific dietary issues that can be addressed directly to improve the child’s health.
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