An adult client exhibits an allergic reaction to an insect bite. The nurse should observe the client's skin for which finding?

Papules.

Excoriation.

Wheals.

Fissuring.

Answer and Explanation

The Correct Answer is C

A) Papules: Papules are small, raised, solid bumps on the skin that are typically less than 1 centimeter in diameter. They can be a result of various skin conditions, but they are not specifically associated with allergic reactions to insect bites.

B) Excoriation: Excoriation refers to a scratch or abrasion on the surface of the skin, often resulting from scratching due to itching. While this can occur secondary to an allergic reaction, it is not a primary characteristic of such reactions.

C) Wheals: Wheals, also known as hives or urticaria, are raised, red or skin-colored welts on the skin that often itch and can appear rapidly in response to an allergen such as an insect bite. They are a characteristic feature of allergic reactions and are caused by the release of histamine.

D) Fissuring: Fissuring refers to deep cracks or splits in the skin. While it can occur in various skin conditions, it is not a typical manifestation of an allergic reaction to an insect bite.

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Correct Answer is B

Explanation

A) Retracted and non-mobile tympanic membrane: This finding is typically associated with conditions such as eustachian tube dysfunction or negative middle ear pressure, not with the symptoms described in this scenario.

B) Red, edematous ear canal with no visualization of the tympanic membrane: This description aligns with otitis externa, commonly known as "swimmer's ear." The client's history of recent swimming, itching, pain, and discharge with a musty odor are classic signs of this condition. In otitis externa, the ear canal often appears red and swollen, and the inflammation can obstruct the view of the tympanic membrane.

C) Translucent, pearly gray and mobile tympanic membrane: This appearance indicates a normal, healthy ear and is inconsistent with the symptoms of pain, itching, and discharge described by the client.

D) Thickened and bulging tympanic membrane: This finding is more indicative of otitis media with effusion or acute otitis media, where fluid or pus collects behind the eardrum, causing it to bulge. However, it does not match the scenario of external ear canal inflammation and discharge following swimming.

A. Takes an oral anticoagulant. B. Works in a day care center. C. Recently had dental surgery. D. Adheres to a gluten free diet.

Correct Answer is A

Explanation

Ecchymosis refers to the discoloration of the skin resulting from bleeding underneath, typically due to bruising. While ecchymosis can occur for various reasons, the use of oral anticoagulants increases the risk of bleeding and bruising. Therefore, the nurse should further assess the client's use of oral anticoagulants to determine if it is contributing to the observed ecchymosis.

B. Works in a day care center:
Working in a day care center may expose the client to various infectious agents, but it is not directly associated with the development of ecchymosis.

C. Recently had dental surgery:
While dental surgery can sometimes result in minor bleeding and bruising, it is less likely to cause widespread ecchymosis unless there are underlying bleeding disorders or complications.

D. Adheres to a gluten-free diet:
Adhering to a gluten-free diet is not directly related to the development of ecchymosis. However, if the client has celiac disease or another condition requiring a gluten-free diet, the nurse should explore the potential for malabsorption or nutritional deficiencies, which could indirectly contribute to bleeding tendencies.

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An adult client exhibits an allergic reaction to an insect bite. The nurse should observe the client's skin for which finding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client presents with itching and pain in the left ear that started several days after beginning swim lessons. The nurse observes a discharge coming from the ear with a musty odor. How should the nurse expect the ear to appear when performing an otoscopic examination?

Correct Answer is B

Explanation

When inspecting the client's skin, the nurse observes several areas of ecchymosis on the trunk and extremities. Which information in the client's history requires additional follow-up by the nurse?

Correct Answer is A

Explanation

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