A client who is admitted for an acute stroke reports the onset of a burning sensation in the hands and legs. Which action should the nurse implement to identify additional findings that are consistent with the client's paresthesia?

Review the client's serum electrolytes.

Evaluate client's muscle strength and hand grips.

Check distal phalanges capillary refill.

Observe skin for erythema, edema, and warmth.

Answer and Explanation

The Correct Answer is B

Choice A Reason:
Reviewing the client's serum electrolytes is incorrect. While abnormalities in electrolyte levels can sometimes contribute to neurological symptoms, such as paresthesia, reviewing the client's serum electrolytes may not directly identify additional findings consistent with the client's reported paresthesia of the hands and legs. Therefore, this option is less relevant for assessing paresthesia and identifying additional consistent findings.
Choice B Reason:
This is the correct action to identify additional findings consistent with the client's paresthesia. Paresthesia, or abnormal sensations like burning or tingling, may indicate neurological dysfunction. Assessing the client's muscle strength and hand grips can provide valuable information about neurological function and help identify any weakness or changes that may be associated with the paresthesia.
Choice C Reason:
Checking distal phalanges capillary refill is incorrect. Checking distal phalanges capillary refill is important for assessing peripheral circulation, but it may not directly identify additional findings consistent with paresthesia. While impaired circulation could contribute to sensory disturbances, such as paresthesia, it is not always the primary cause. Therefore, this option may not fully capture the sensory aspect of the client's reported symptoms.
Choice D Reason:
While observing the skin for signs of inflammation or irritation is important in assessing for other conditions, such as infection or inflammation, it is not directly related to identifying additional findings consistent with paresthesia. Paresthesia primarily involves abnormal sensations and neurological function rather than changes in the skin.

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Correct Answer is ["D","F"]

Explanation

Choice A Reason:
Macule is incorrect. A macule is a flat, discolored spot on the skin that is less than 1 centimeter in diameter. It does not contain fluid; instead, it represents a change in the color of the skin, such as a freckle or a flat mole. Macules are not filled with fluid; they are characterized by alterations in skin pigmentation without any elevation or depression.
Choice B Reason:
Papule is incorrect. A papule is a small, raised bump on the skin that is less than 1 centimeter in diameter. Papules do not contain fluid; instead, they result from localized cellular infiltration, inflammation, or proliferation in the skin layers. Examples of papules include acne lesions and insect bites.
Choice C Reason:
While often confused with fluid-filled sacs, a wheal is an area of localized dermal edema. They are solid, itchy, and irregularly shaped (e.g., hives or insect bites).
Choice D Reason:
Vesicle is correct. A vesicle is a small, fluid-filled blister that appears on the skin. It contains clear fluid and can be caused by various factors such as infection, allergic reactions, or friction.
Choice E Reason:
Nodule is incorrect. A nodule is a solid, raised bump on the skin that is larger than 1 centimeter in diameter and extends into deeper layers of the skin. Similar to papules, nodules do not contain fluid; they are composed of tissue, such as fat, fibrous tissue, or tumors. Examples of nodules include lipomas and dermatofibromas.
Choice F Reason:
Pustule is correct. A pustule is a small, pus-filled blister that appears on the skin. It contains purulent fluid (pus) and is often associated with bacterial infections such as acne or folliculitis.

A. Allow the client to decline answering social questions. B. Obtain a drug urine screen to verify legitimacy of client's stated history. C. Use the term illegal or illicit to describe street drugs. D. Ask specifically about alcohol, marijuana, cocaine, heroin, and amounts.

Correct Answer is D

Explanation

Choice A Reason:
Allowing the client to decline answering social questions is inappropriate. This approach respects the client's autonomy and privacy by giving them the option to decline answering questions they may feel uncomfortable or unwilling to discuss. However, for the purpose of ensuring comprehensive care and assessing potential risks associated with substance use, it's important for the nurse to gather relevant information about the client's use of illegal drugs and alcohol.
Choice B Reason:
Obtaining a drug urine screen to verify legitimacy of client's stated history is inappropriate. While obtaining a drug urine screen may provide objective information about recent drug use, it may not be indicated during the initial health history and may not accurately reflect the client's past substance use history. Additionally, relying solely on laboratory testing without actively engaging the client in open communication may hinder the development of trust and rapport between the client and the healthcare provider.
Choice C Reason:
Using the term illegal or illicit to describe street drugs is inappropriate. Using the terms "illegal" or "illicit" may carry negative connotations and could potentially stigmatize the client's substance use. This approach may create barriers to open communication and may not accurately capture the client's experiences or perceptions regarding their substance use. Additionally, it's important to use language that is respectful and nonjudgmental when discussing sensitive topics such as substance use.
Choice D Reason:
Asking specifically about alcohol, marijuana, cocaine, heroin, and amounts is appropriate. This approach is the most appropriate because it directly addresses the substances of concern and allows for comprehensive assessment of the client's substance use history. By asking specifically about commonly used substances and their amounts, the nurse ensures that key information is gathered in a respectful and nonjudgmental manner, facilitating open communication and accurate assessment of the client's needs.

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A client who is admitted for an acute stroke reports the onset of a burning sensation in the hands and legs. Which action should the nurse implement to identify additional findings that are consistent with the client's paresthesia?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Patient Data Exhibits During the assessment, the nurse notes that the areas are filled with a fluid-like substance. Which of the following primary skin lesions contain fluid? Select all that apply.

Correct Answer is ["D","F"]

Explanation

The nurse is obtaining a health history for a client prior to a scheduled cholecystectomy. While interviewing the client, which assessment technique should the nurse use when asking about the client's use of illegal drugs and alcohol?

Correct Answer is D

Explanation

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