A 45-year-old client with dark skin tone comes to the clinic complaining of fatigue, thirst, and frequent urination. During the examination, the nurse notices areas of hyperpigmentation around the neck and in the axillae. What is the priority intervention by the nurse?
Refer the client for medical follow-up in two weeks.
Document the benign findings.
Perform a random blood sugar test per order.
Ask the client about a family history of cancer.
The Correct Answer is C
A. Delaying follow-up for two weeks is inappropriate when symptoms suggest a possible serious metabolic disorder, such as diabetes. Immediate testing is needed.
B. Simply documenting the findings as benign is incorrect because hyperpigmentation in these areas (acanthosis nigricans) can be a sign of insulin resistance, which requires further evaluation.
C. Performing a random blood sugar test per order is correct. The symptoms of fatigue, thirst, and frequent urination, along with acanthosis nigricans, strongly suggest diabetes mellitus or insulin resistance. A random blood glucose test can help determine if the client has hyperglycemia.
D. While certain malignancies can be associated with acanthosis nigricans, diabetes is a more common cause. Asking about cancer history is not the priority intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. While diagnostic testing and medical history are important, this response does not acknowledge the client’s frustration or emphasize the purpose of the assessment.
B. This response is too general and does not provide reassurance to the client.
C. While this statement is true, it does not clearly explain why the history is necessary in a way that involves the client.
D. "This information will help me to plan individualized nursing care with you" is correct because it directly explains the purpose of the assessment and involves the client in their care.
Correct Answer is D
Explanation
A. The colon does not secrete bile; bile is produced by the liver and stored in the gallbladder.
B. The colon does absorb electrolytes, but its primary function is water absorption, which helps form solid stool.
C. The colon does not secrete digestive enzymes; enzyme secretion occurs primarily in the stomach and small intestine.
D. The colon's primary function is absorbing large amounts of water, which helps maintain fluid balance and form feces. Disruptions, such as in colon cancer, can lead to diarrhea or constipation.
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