A nurse is collecting data from a client who has an exacerbation of gout. Which of the following findings should the nurse expect? (Select all that apply.)
Tight skin
Edema
Tophi
Symmetrical joint pain
Erythema
Correct Answer : B,C,E
A nurse collecting data from a client who has an exacerbation of gout should expect to find edema, tophi, and erythema. Gout is a type of arthritis that occurs when urate crystals accumulate in the joints, causing inflammation and intense pain. Edema (swelling) is a common symptom of gout⁴. Tophi are deposits of urate crystals that can form under the skin in people with chronic gout³. Erythema (redness) is another common symptom of gout⁴.
a. Tight skin is not a common symptom of gout.
d. Symmetrical joint pain is not a common symptom of gout, as it usually affects only one joint at a time.
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Related Questions
Correct Answer is C
Explanation
An appropriate action to prevent hip dislocation in a client who is postoperative following a total hip arthroplasty is to place a wedge pillow between the legs. This helps to maintain proper alignment and prevent the legs from crossing or adducting, which can cause hip dislocation.
Placing a trochanter roll against the thigh, placing a sandbag on the lateral calf, and placing a footboard on the bed are not appropriate actions to prevent hip dislocation in this situation. A trochanter roll is used to prevent external rotation of the hip. A sandbag to the lateral calf can help prevent foot drop. A footboard can help prevent plantar flexion contractures.
Correct Answer is A
Explanation
The correct answer is choice A. The client requires total nursing care.
Choice A rationale:
A Glasgow Coma Scale (GCS) score of 8 indicates a severe head injury and significant impairment in consciousness. Clients with a GCS score of 8 or less are often unable to perform basic activities of daily living independently and require total nursing care.
Choice B rationale:
A GCS score of 8 does not indicate a deep coma. Deep coma is typically associated with a GCS score of 3-4, where the client shows minimal to no response to stimuli.
Choice C rationale:
A client who is alert and oriented would have a much higher GCS score, typically between 13 and 15. A score of 8 indicates significant impairment in consciousness, not alertness and orientation.
Choice D rationale:
A GCS score of 8 does not suggest stable neurological status. Instead, it indicates severe neurological impairment, requiring close monitoring and comprehensive care.
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