An adult client exhibits an allergic reaction to an Insect bite. The nurse should observe the client's skin for which finding?
Excoriation.
Papules.
Wheals.
Fissuring.
The Correct Answer is C
Choice A Reason:
Excoriation is incorrect. Excoriation refers to scratch marks or abrasions on the skin caused by scratching or rubbing. While excoriation can occur as a result of scratching due to itching caused by an allergic reaction, it is not a specific characteristic of an allergic reaction to an insect bite. However, it may develop secondary to the itching associated with insect bites.
Choice B Reason:
Papules are incorrect. Papules are small, raised bumps on the skin that can have various causes, including insect bites. While papules can sometimes accompany an allergic reaction to insect bites, they are not as characteristic as wheals (hives) in such reactions. Papules may also represent other skin conditions or reactions, so they are not as specific to allergic reactions as wheals.
Choice C Reason:
Wheals are correct. Wheals, also known as hives or urticaria, are raised, red, itchy areas of the skin that often occur as part of an allergic reaction to insect bites, medications, foods, or other allergens. Wheals are typically transient and can vary in size and shape. Excoriation (choice A) refers to scratch marks or abrasions on the skin caused by scratching or rubbing.
Choice D Reason:
Fissuring is incorrect. Fissuring refers to deep cracks or splits in the skin's surface. Fissures are not typically associated with allergic reactions to insect bites. Instead, they may occur in conditions such as eczema, psoriasis, or severe dry skin. Therefore, while skin fissuring may occur in some skin conditions, it is not a typical finding in allergic reactions to insect bites.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
Epigastric region is correct. The epigastric region is the area of the abdomen located between the lower part of the ribcage and the navel (umbilicus). Pain localized in the middle section of the abdomen below the xiphoid process corresponds to the epigastric region. This region encompasses the upper part of the stomach and the lower part of the esophagus, making it a common location for discomfort related to conditions such as gastritis, peptic ulcer disease, or gastroesophageal reflux disease (GERD).
Choice B Reason:
Hypogastric region is incorrect. The hypogastric region is located in the lower part of the abdomen, below the umbilical region. Pain in the hypogastric region typically corresponds to the lower abdomen, around the pubic bone, and may be associated with conditions such as bladder infections, menstrual cramps, or pelvic inflammatory disease.
Choice C Reason:
Hypochondriac region is incorrect. The hypochondriac regions are located on each side of the upper abdomen, beneath the ribs. Pain in the hypochondriac region may be associated with conditions affecting the liver, gallbladder, or spleen, but it does not correspond to the description provided by the client.
Choice D Reason:
Umbilical region is incorrect. The umbilical region is located around the navel (umbilicus) in the center of the abdomen. Pain in the umbilical region may be associated with conditions affecting the small intestine or structures around the navel, such as umbilical hernias. However, it does not specifically correspond to the description of pain below the xiphoid process in the middle section of the abdomen.
Correct Answer is C
Explanation
Choice A Reason:
Purulent secretions from eyes and nares is incorrect. Purulent secretions, which are thick and yellow or green in color, typically indicate the presence of a bacterial infection rather than allergic rhinitis. Allergic rhinitis is more commonly associated with clear nasal discharge, although it can sometimes be accompanied by a mild increase in nasal secretions.
Choice B Reason:
Snoring and bilateral, pale gray nodules is incorrect. Snoring and bilateral, pale gray nodules suggest adenoid hypertrophy rather than allergic rhinitis. Adenoid hypertrophy refers to enlargement of the adenoids, which are lymphoid tissue located in the back of the nasal cavity. Enlarged adenoids can lead to snoring and the presence of grayish nodules upon examination of the nasopharynx.
Choice C Reason:
Intranasal edema and swelling of turbinates are correct. Intranasal edema (swelling inside the nose) and swelling of turbinates are characteristic features of allergic rhinitis. Allergic rhinitis results from inflammation of the nasal mucosa in response to exposure to allergens, leading to nasal congestion and swelling of the turbinates.
Choice D Reason:
Eye tearing and thick yellow nasal drainage is incorrect. Eye tearing and thick yellow nasal drainage suggest the presence of sinusitis rather than allergic rhinitis. Sinusitis is characterized by inflammation of the sinuses, which can result in symptoms such as facial pain or pressure, thick nasal discharge, and eye tearing due to sinus pressure affecting the tear ducts.
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