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

Answer and Explanation

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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Correct Answer is C

Explanation

Decorticate posturing is a specific type of involuntary abnormal posturing of a person that is a sign of severe damage to the brain¹. In decorticate posture, the arms are bent to hold the hands on the chest and the fists are clenched¹. The hands may each twist inward at the wrists with knuckles facing or touching each other. This is known as the pronation of the hands.

Extension of the extremities is not a characteristic of decorticate posturing. Extension of the extremities is more characteristic of decerebrate posturing, where arms and legs are straight and rigid¹.

External rotation of the lower extremities is not a characteristic of decorticate posturing. In decorticate posture, legs are held out straight¹.

Plantar ﬂexion of the legs is not a characteristic of decorticate posturing. In decorticate posture, legs are held out straight¹.

A. Uneven cast drying B. Infection C. Pressure from the cast D. Poor circulation

Correct Answer is B

Explanation

The nurse should identify infection as a complication to the client's condition. A warm area on the cast could indicate the presence of an underlying infection. The warmth could be due to an increase in blood ﬂow to the area as the body tries to fight oﬀ the infection.

Uneven cast drying, pressure from the cast, and poor circulation are not complications that would cause a warm area on the cast. Uneven cast drying could cause discomfort but would not result in warmth. Pressure from the cast could cause skin breakdown but would not result in warmth. Poor circulation could cause coolness or pallor but would not result in warmth.

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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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who has increased intracranial pressure and is informed by the charge nurse that the client demonstrates decorticate posturing. Which of the following findings should the nurse expect to observe?

Correct Answer is C

Explanation

While collecting data from a client who has a cast on his right leg, a nurse locates an area on the cast that feels warm to the touch. Which of the following findings should the nurse identify as a complication to the client's condition?

Correct Answer is B

Explanation

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