A 45-year-old African-American client comes to the clinic complaining of fatigue, thirst, and frequent urination. During the physical exam, the nurse notices areas of linear hyperpigmentation around the neck and in the axillae (Acanthosis Nigricans). What would the nurse do next?

Refer the client for medical follow-up.

Ask the client about a family history of cancer.

Document the benign findings.

Perform a random blood sugar test.

Answer and Explanation

The Correct Answer is A

Choice a reason :
Referring the client for medical follow-up is the most appropriate action. Acanthosis Nigricans is often associated with insulin resistance and is a risk factor for diabetes mellitus. The client's symptoms of fatigue, thirst, and frequent urination are classic signs of diabetes. Therefore, a comprehensive medical evaluation is necessary to rule out diabetes or other underlying conditions that could be causing these symptoms.
Choice b reason
While Acanthosis Nigricans can sometimes be associated with malignancy, it is more commonly linked to insulin resistance and diabetes. The client's presenting symptoms are not typical of cancer but are indicative of diabetes. Therefore, while a family history of cancer is relevant to the client's overall health, it is not the immediate concern based on the current presentation.
Choice c reason
Documenting findings is an essential part of the nursing process; however, the presence of Acanthosis Nigricans, especially when coupled with symptoms of fatigue, thirst, and frequent urination, should not be considered benign without further investigation. These findings warrant further assessment to determine the underlying cause.
Choice d reason
Performing a random blood sugar test could be a part of the initial assessment; however, it should not replace a referral for a comprehensive medical evaluation. A random blood sugar test alone may not be sufficient to diagnose diabetes or determine the cause of the client's symptoms. A full medical follow-up will likely include blood sugar testing along with other diagnostic tests.

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Correct Answer is C

Explanation

Choice a reason:
Assisting the client to a sitting position is not the best action to ensure that bowel sounds can be heard. For abdominal auscultation, the patient should be lying down in a supine position to relax the abdominal muscles, which facilitates the hearing of bowel sounds.

Choice b reason:
Percussion of the abdomen before auscultation is not recommended as the best initial action. Percussion can stimulate bowel motility, which may alter the natural bowel sounds that the nurse is attempting to assess.

Choice c reason:
Reducing all environmental noise is the best action to ensure that bowel sounds can be heard clearly. Environmental noise can mask the subtle sounds of bowel motility, and minimizing distractions allows for a more accurate assessment of bowel activity.

Choice d reason:
Palpating the region before auscultating is not the best action because palpation can also stimulate bowel motility and potentially alter the bowel sounds. Auscultation should be performed before palpation during the abdominal examination to avoid this issue.

A. Temperature B. Vibrations C. Pulses D. Fremitus

Correct Answer is C

Explanation

Choice A Reason:
The dorsal aspect of the hand, rather than the finger pads, is more sensitive to temperature due to its thinner skin. Therefore, while the finger pads can detect temperature, they are not the best tool for this purpose.

Choice B Reason:
Vibrations, such as those produced by vocal fremitus, are typically assessed using the ulnar edge or the palmar aspect of the hand, not the finger pads. The finger pads are sensitive but do not provide the best surface for detecting vibrations.

Choice C Reason:
The finger pads are densely innervated and are the most sensitive part of the hand, making them ideal for palpating pulses. Pulses are subtle and require a fine touch to assess properly, which is why the finger pads are the preferred area for this assessment.

Choice D Reason:
Fremitus refers to the palpable vibrations transmitted through the bronchopulmonary tree to the chest wall as someone speaks. It is best felt with the ball of the hand or the ulnar edge, not the finger pads.

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A 45-year-old African-American client comes to the clinic complaining of fatigue, thirst, and frequent urination. During the physical exam, the nurse notices areas of linear hyperpigmentation around the neck and in the axillae (Acanthosis Nigricans). What would the nurse do next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse working in an outpatient GI clinic is conducting a physical examination of the abdomen. What is the nurse's best action to ensure she can hear bowel sounds?

Correct Answer is C

Explanation

The nurse is using the finger pads of the hand to palpate a body part. Which finding would the nurse be best able to detect?

Correct Answer is C

Explanation

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