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 D

Explanation

The nurse should expect to find edema of the toes first if the cast is too tight. A cast that is too tight can impede blood flow and cause swelling (edema) of the toes. If the nurse notices edema of the toes, they should report this finding to the provider and take appropriate action to prevent further complications.

Toes cool to touch may occur if the cast is too tight but this is not typically the first finding.

The inability to move toes may occur if the cast is too tight but this is not typically the first finding.

The pallor of the toes may occur if the cast is too tight but this is not typically the first finding.

A. Edematous bruise on forehead B. Client disoriented to place C. Heart rate 110/min and regular D. Small drops of clear ﬂuid in the left ear

Correct Answer is D

Explanation

The nurse should immediately report small drops of clear ﬂuid in the left ear to the charge nurse. This finding could indicate a cerebrospinal ﬂuid (CSF) leak, which can occur as a result of a head injury. A CSF leak can be a serious medical condition that requires immediate attention.

An edematous bruise on the forehead, client disorientation to place, and a heart rate of 110/min and regular are also important findings that the nurse should report to the charge nurse. However, these findings are not as urgent as the presence of small drops of clear ﬂuid in the left ear.

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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

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Correct Answer is D

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