A client with red scaling papules on his elbows, knees, lower back, and scalp arrives to the clinic. Which of the following questions will the nurse include in her assessment?
Do the lesions hurt?
Do the lesions worsen when you eat certain foods?
Have you noticed a decrease in lesions after starting antibiotics?
How do you spend your weekends?
The Correct Answer is A
Choice A reason: This is the correct answer because this question will help the nurse assess the pain level and discomfort of the client with red scaling papules. Red scaling papules are raised skin lesions that are red and covered with scales. They can indicate psoriasis, which is a chronic skin condition that causes inflammation and rapid turnover of skin cells. Psoriasis can cause pain, itching, burning, or stinging sensations in the affected areas. The nurse should ask the client to rate their pain on a numeric or descriptive scale and provide analgesics or topical agents as prescribed.
Choice B reason: This is incorrect because this question will not help the nurse assess the condition of the client with red scaling papules. Red scaling papules are not affected by food intake but by other factors such as stress, infection, injury, or medication. Psoriasis is not an allergic or dietary disorder, but an immune-mediated disorder that causes abnormal skin cell growth. The nurse should ask the client about their medical history, current medications, and triggers or aggravating factors for their psoriasis.
Choice C reason: This is incorrect because this question will not help the nurse assess the condition of the client with red scaling papules. Red scaling papules are not treated with antibiotics but with other medications such as corticosteroids, immunosuppressants, or biologics. Antibiotics are used to treat bacterial infections, which are not the cause of psoriasis. The nurse should ask the client about their treatment regimen, compliance, and effectiveness for their psoriasis.
Choice D reason: This is incorrect because this question will not help the nurse assess the condition of
the client with red scaling papules. Red scaling papules are not related to weekend activities but to chronic skin inflammation and abnormal cell turnover. Psoriasis is not a lifestyle disorder, but a genetic disorder that can be influenced by environmental factors. The nurse should ask the client about their family history, exposure to sun or cold, and stress level for their psoriasis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason: Depth perception is the ability to judge the distance and position of objects in three-dimensional space. Depth perception is assessed by asking the client to touch the tip of a pen or pencil held by the nurse, or by using a stereopsis test.
Choice B Reason: Peripheral vision is the ability to see objects and movements outside the direct line of vision. Peripheral vision is assessed by asking the client to shake the hand of the nurse, who stands at an angle to the client's side, or by using a confrontation test.
Choice C Reason: Color deficit is the inability to distinguish certain colors or shades of colors. Color deficit is assessed by asking the client to identify numbers or shapes on a color plate test, such as the Ishihara test.
Choice D Reason: Double vision is the perception of two images of a single object. Double vision is assessed by asking the client to cover one eye and look at an object, then switch eyes and compare the images, or by using a cover-uncover test.
Correct Answer is D
Explanation
Choice A reason: This is incorrect because this comment does not require reporting to the client's provider. It is normal to have reduced vision and an increased risk of falling with a patch on one eye after cataract surgery. The nurse should reassure the client, provide assistance with mobility, and educate the client on safety measures.
Choice B reason: This is incorrect because this comment does not require reporting to the client's provider. It is normal to have some itching and discomfort in the eye after cataract surgery. The nurse should commend the client for not rubbing the eye, as this can cause infection or damage to the surgical site. The nurse should also administer anti-inflammatory eye drops as prescribed and instruct the client on how to apply them.
Choice C reason: This is incorrect because this comment does not require reporting to the client's provider. It is normal to have increased sensitivity to light in the eye after cataract surgery. The nurse should dim the lights in the room, provide sunglasses or a shield for the eye, and educate the client on how to protect the eye from bright light.
Choice D reason: This is the correct answer because this comment requires reporting to the client's provider. Severe pain in the eye after cataract surgery can indicate a complication such as infection, inflammation, bleeding, or increased intraocular pressure. The nurse should assess the eye for signs of redness, swelling, discharge, or bleeding, and report the findings and the pain level to the provider. The nurse should also administer analgesics as prescribed and monitor the pain relief.
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