When inspecting a client's skin, the nurse observes an area of erythema on the arm. Which follow- up assessment should the nurse complete?

Measure the degree of skin elasticity.

Palpate the area for warmth and swelling.

Determine the client's oxygen saturation.

Observe the appearance of the nailbeds.

Answer and Explanation

The Correct Answer is B

A.   Skin elasticity is assessed by pinching the skin to see how quickly it returns to its normal position, which is often done to evaluate hydration status or the presence of dehydration. While skin elasticity is an important overall assessment of skin health, it is not directly related to the assessment of erythema.
B.   Palpating the erythematous area for warmth and swelling is a crucial follow-up assessment. Erythema (redness of the skin) can be a sign of inflammation or infection, and the presence of warmth and swelling can help determine if the area is inflamed or if there might be an underlying infection.
C.   Oxygen saturation measurements assess the level of oxygen in the blood, typically using a pulse oximeter. While oxygen saturation is important for assessing overall respiratory and circulatory health, it is not directly related to evaluating the cause or characteristics of erythema. Therefore, this would not be the most relevant follow-up assessment for a red area on the skin.
D.   Observing the appearance of the nailbeds can provide information about overall circulation and oxygenation, but it is not directly related to assessing a localized area of erythema on the skin. Changes in the nailbeds can indicate systemic conditions but would not provide specific information about the erythematous area in question.

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Correct Answer is C

Explanation

A. Significant weight loss can be a concern for overall health and may be related to various conditions, including nutritional deficiencies. However, weight loss alone does not specifically indicate the need for bone density screening. It may be a factor in a broader health assessment but is not a direct indicator for bone density measurement.
B. A diminished appetite can affect nutritional intake, which in turn may impact bone health over time. However, diminished appetite itself does not directly suggest a need for a bone density screening unless it leads to significant weight loss or is part of a broader concern about nutritional status affecting bone health.
C. Decreased height is a key indicator that may suggest osteoporosis or significant bone loss. This can be due to vertebral compression fractures, which are common in individuals with osteoporosis. A reduction in height over time can be a direct sign that warrants a bone density screening to assess bone health and risk for fractures.
D. A lower BMI can be associated with lower bone mass and increased risk for osteoporosis, particularly in individuals who are underweight. However, while a low BMI can be a risk factor for osteoporosis, it is not as specific as decreased height for prompting a bone density screening.

A. "No, of course not." B. "I smoked marijuana before, but only once." C. "What would you classify as recreational?" D. "I've been known to on occasion."

Correct Answer is A

Explanation

A. This response is a straightforward denial. It reflects a direct and possibly automatic answer that the client does not use recreational drugs. However, this type of response might be influenced by the phrasing of the question, which could lead the client to respond in a way that aligns with what they perceive as socially acceptable or expected.
B. This response indicates that the client acknowledges past use of a recreational drug (marijuana) but minimizes its frequency and significance. The response suggests that the phrasing of the question might have led the client to clarify their past behavior, showing an attempt to be honest while downplaying the extent of use.

C. This response suggests that the client is seeking clarification on what the term "recreational drugs" includes. The question might have been vague or broad, prompting the client to ask for a definition or to specify which substances are considered recreational drugs. This response indicates that the client might be unsure about whether their drug use falls into the category of recreational drugs.
D. This response implies that the client does use recreational drugs but does so infrequently or sporadically. It suggests a level of acknowledgment of occasional use without providing specifics. This type of answer might reflect that the client is uncomfortable with a direct yes/no response and opts for a more ambiguous acknowledgment.

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When inspecting a client's skin, the nurse observes an area of erythema on the arm. Which follow- up assessment should the nurse complete?

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Naxlex Comprehensive Predictor Exams

During a routine health screening of an adult female, the nurse notes several changes that have occurred over the past year. Which change indicates the need for a bone density screening?

Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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