A nurse is collecting data from a group of clients. Which of the following images indicates a client the nurse should identify as exhibiting clubbing of the fingers?
<p><img src="https://naxlex.com/nursing/assets/images/study_guides/Picture1a_1746702749.jpg" class="img-fluid" /></p>
<p><img src="https://naxlex.com/nursing/assets/images/study_guides/Picture1b_1746702798.jpg" class="img-fluid" /></p>
The Correct Answer is A
A: Image A shows hands with fingers that appear elongated and have widened nail beds. The fingertips look rounded and bulbous, which is characteristic of clubbing. Clubbing often results from chronic hypoxia and is seen in conditions like congenital heart disease, cystic fibrosis, and chronic lung disease.
B: Image B shows normal-appearing fingers with straight nail beds and no signs of bulbous enlargement at the fingertips. This appearance is not consistent with clubbing and represents normal finger structure without signs of chronic hypoxia or circulatory issues.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Black out the line with a felt-tip pen: Blacking out a space or entry is inappropriate because it obscures the original documentation, making the record appear altered or falsified. Medical documentation must remain clear, transparent, and legally defensible at all times.
B. Draw a horizontal line through the space and sign at the end of the line: Drawing a single horizontal line through the blank space ensures that no unauthorized additions can be made later. Signing at the end of the line maintains the integrity and completeness of the medical record, following accepted documentation standards.
C. Place the date at the beginning of the space, followed by double lines: Simply dating the space without properly securing it with a line could leave it open to later insertions. Double lines are also not a recognized standard method for handling blank spaces in documentation.
D. Leave the space as it is within the entry: Leaving a blank space unmarked can create opportunities for someone to add unauthorized information later. This poses legal and ethical risks and compromises the reliability and security of the medical record.
Correct Answer is A
Explanation
A. Ask the client to identify what made them upset: The first action should be to assess and de-escalate the situation using therapeutic communication. Asking the client to verbalize their feelings can help reduce agitation, promote self-awareness, and prevent escalation.
B. Assist the client with understanding their needs: Helping the client understand their needs is important but comes after first addressing and calming their immediate emotional agitation through assessment and supportive conversation.
C. Place the client in seclusion: Seclusion is a last-resort intervention when the client poses a danger to themselves or others and less restrictive measures have failed. It should not be the first action without attempting de-escalation techniques.
D. Administer lorazepam IM: Administering medication is appropriate if non-pharmacological interventions fail. However, medication should not be the first response before attempting verbal de-escalation strategies in an agitated client.
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