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

Explanation

Choice A Reason:
Expected finding is incorrect. While some degree of dullness is expected during percussion of the heart borders due to the presence of solid cardiac tissue, the specific pattern described in the scenario, extending from the 5th left intercostal space to the 2nd left intercostal space at the sternal border, suggests an abnormality rather than an expected finding.
Choice B Reason:
Cardiac atrophy is incorrect. Cardiac atrophy refers to a decrease in the size or mass of the heart muscle, resulting in a smaller than normal heart. However, the described findings indicate dullness extending upward, suggesting an enlargement rather than atrophy of the heart.
Choice C Reason:
Benign variation is incorrect. Benign variations in cardiac percussion findings are less likely to produce a pattern of dullness extending from the 5th left intercostal space to the 2nd left intercostal space at the sternal border. This pattern is more indicative of cardiac enlargement or pathology rather than a benign variation.
Choice D Reason:
Cardiac enlargement is correct. During percussion of the heart borders, dullness indicates solid tissue, such as the heart. The area of dullness extending from the 5th left intercostal space to the 2nd left intercostal space at the sternal border suggests an enlargement of the cardiac silhouette. This enlargement could be due to various cardiac conditions, such as cardiomegaly (enlarged heart), left ventricular hypertrophy, or other structural abnormalities affecting the heart.

A. Excoriation. B. Papules. C. Wheals. D. Fissuring.

Correct Answer is C

Explanation

Choice A Reason:
Excoriation is incorrect. Excoriation refers to scratch marks or abrasions on the skin caused by scratching or rubbing. While excoriation can occur as a result of scratching due to itching caused by an allergic reaction, it is not a specific characteristic of an allergic reaction to an insect bite. However, it may develop secondary to the itching associated with insect bites.
Choice B Reason:
Papules are incorrect. Papules are small, raised bumps on the skin that can have various causes, including insect bites. While papules can sometimes accompany an allergic reaction to insect bites, they are not as characteristic as wheals (hives) in such reactions. Papules may also represent other skin conditions or reactions, so they are not as specific to allergic reactions as wheals.
Choice C Reason:
Wheals are correct. Wheals, also known as hives or urticaria, are raised, red, itchy areas of the skin that often occur as part of an allergic reaction to insect bites, medications, foods, or other allergens. Wheals are typically transient and can vary in size and shape. Excoriation (choice A) refers to scratch marks or abrasions on the skin caused by scratching or rubbing.
Choice D Reason:
Fissuring is incorrect. Fissuring refers to deep cracks or splits in the skin's surface. Fissures are not typically associated with allergic reactions to insect bites. Instead, they may occur in conditions such as eczema, psoriasis, or severe dry skin. Therefore, while skin fissuring may occur in some skin conditions, it is not a typical finding in allergic reactions to insect bites.

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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

While percussing the borders of the heart, the nurse picks up an area of dullness beginning at the 5th left intercostal space and moving upward to the 2nd left intercostal space at the sternal border. What do these findings indicate?

Correct Answer is D

Explanation

An adult client exhibits an allergic reaction to an Insect bite. The nurse should observe the client's skin for which finding?

Correct Answer is C

Explanation

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