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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The first action the nurse should take is to check the client for injuries. The nurse should assess the client for any signs of injury or trauma and provide appropriate care as needed.
Obtaining a prescription for medication to sedate the client, calling the family and asking them to make arrangements for someone to sit with the client, assisting the client back into bed, and applying restraints are not appropriate initial actions for the nurse to take in this situation. These actions may be considered after the client has been assessed for injuries and their immediate needs have been addressed.
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.
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