A homeless male client with a history of alcohol abuse had a cerebrovascular accident (CVA) 10 years ago that resulted in left hemiparesis. Today he is reporting pain in his left leg, is afebrile, has 4+ pitting edema in the lower left leg, and minimal swelling of the right leg. Which action should the nurse implement first?

Complete a mental status exam.

Obtain a blood alcohol level.

Inspect legs for infection or trauma.

Inquire about dietary salt intake.

Answer and Explanation

The Correct Answer is C

A.   The client’s current symptoms—pain, significant leg edema, and swelling—are more pressing and suggest a need to evaluate the physical cause of these symptoms rather than focusing immediately on mental status.
B.   Obtaining a blood alcohol level might be relevant if there is a suspicion that recent alcohol use is contributing to the client’s condition or affecting his overall health. However, the primary concern in this case is the significant edema and pain in the left leg.
C.   This is the most pertinent action to take first. The client’s symptoms of severe edema and pain in one leg, along with a history of CVA and alcohol abuse, raise concerns about possible causes such as deep vein thrombosis (DVT), infection, or trauma. Inspecting the legs for signs of infection or trauma (bruising, cuts) is crucial to determine the underlying cause of the symptoms and guide appropriate treatment.

D.   While excessive salt intake can contribute to fluid retention and edema, the degree of swelling described (4+ pitting edema) and the localized nature of the problem in the left leg make it less likely that dietary salt alone is the cause.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

A. A urine dipstick test is a preliminary screening tool that can quickly provide information about the presence of glucose, protein, nitrites, and leukocytes in the urine. In the context of uncontrolled diabetes with symptoms of painful urination, this test is useful for identifying signs of a urinary tract infection (UTI), which is a common complication in diabetic patients.
B. A rapid strep test is used to diagnose streptococcal infections, particularly strep throat. It is not relevant to the symptoms of frequent and painful urination and does not help in assessing diabetic complications or urinary issues.

C. Nitrazine pH strips are primarily used to assess amniotic fluid in pregnant women to determine if labor has started. They are not used for diagnosing urinary tract infections or evaluating symptoms related to diabetes.
D. A fingerstick glucose test measures blood glucose levels and is useful for assessing the client's current glycemic control. While monitoring blood glucose levels is important for managing diabetes, it does not directly address the issue of painful urination or the presence of a urinary tract infection.

A. Large, flat, dark red irregular area on the neck. B. Multiple silver striae on the abdomen. C. Bluish discoloration of the nailbeds. D. Multiple yellow lesions with a grainy surface.

Correct Answer is A

Explanation

A. This finding is most concerning as it could indicate a melanoma, a type of skin cancer that is highly aggressive and potentially fatal. The characteristics of the lesion - large, flat, dark red, irregular - are consistent with a melanoma.
B. Striae are stretch marks, often caused by rapid weight gain or pregnancy. While they can be unsightly, they are generally not a cause for concern.
C. Bluish discoloration of the nailbeds can be a sign of cyanosis, which may indicate a lack of oxygen in the blood. However, it could also be caused by other factors such as cold temperatures or poor circulation. While this finding should be investigated further, it is not as urgent as a large, irregular, dark red area on the neck.
D. These lesions could be xanthelasmas, which are yellow, fatty deposits often associated with high cholesterol levels. While they are not dangerous, they can be a sign of underlying health issues and should be discussed with a healthcare provider.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is completing an assessment for a client with uncontrolled diabetes mellitus (DM) who came to the clinic reporting frequent, painful urination. Which screening test should the nurse perform first?

Correct Answer is A

Explanation

When assessing a client's skin, which finding should the nurse report to the healthcare provider?

Correct Answer is A

Explanation

Which finding should raise the greatest concern for a nurse who is performing an ear nose and throat (ENT) examination?

A client who recently underwent a routine surgical procedure made a dinic appointment. To elicit the most information, which question is best for the nurse to ask this client?

During a routine health screening of an adult female, the nurse notes several changes that have occurred over the past year. Which change indicates the need for a bone density screening?

The nurse is assessing a client for goiter and is unable to observe the thyroid gland. Which action should the nurse take?

A male client reports the onset of a burning sensation in his hands and legs. How should the nurse document this finding in the electronic medical record (EMR)?

The nurse assesses a male client who is brought to the emergency department (ED) by his family who believes he is having a heart attack. Which finding is the best indicator that a client is experiencing an acute myocardial infarction (AMI)?

In assessing a client's nailbeds, the nurse notes that the angle between the nail and the nailbed is 200 degrees. Which action should the nurse take?