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:
Palpating the client's dorsalis pedis pulses is appropriate because shiny lower legs with no hair growth are characteristic findings of peripheral arterial disease (PAD), which commonly occurs in individuals with diabetes mellitus. Palpating the client's dorsalis pedis pulses allows the nurse to assess peripheral arterial perfusion. Weak or absent dorsalis pedis pulses may indicate decreased blood flow to the feet and lower extremities, supporting the diagnosis of PAD.
Choice B Reason:
Asking if the client often feels weak or hungry is less relevant to the assessment findings of shiny lower legs with no hair growth. While it is important to assess for symptoms of hypoglycemia in clients with diabetes mellitus, such as weakness or hunger, these symptoms do not directly correlate with the observed peripheral vascular changes.
Choice C Reason:
Comparing the range of motion of both legs is less relevant to the assessment findings of shiny lower legs with no hair growth. Range of motion assessment is important for assessing joint function and mobility but does not provide information specifically related to peripheral vascular status.
Choice D Reason:
Measuring the client's capillary glucose is less relevant to the assessment findings of shiny lower legs with no hair growth. While it is important to monitor blood glucose levels in clients with diabetes mellitus, capillary glucose measurement does not provide information specifically related to peripheral vascular status or the observed findings of PAD.
Correct Answer is B
Explanation
Choice A Reason:
Chronic pancreatitis is incorrect. Chronic pancreatitis typically presents with persistent, dull abdominal pain that may radiate to the back, often aggravated by eating rather than relieved by it. The pain associated with chronic pancreatitis is not typically described as gnawing or relieved by eating.
Choice B Reason:
Peptic ulcer disease (PUD) is correct. Peptic ulcer disease involves the development of open sores (ulcers) in the lining of the stomach (gastric ulcers) or the upper part of the small intestine (duodenal ulcers). The pain associated with PUD typically occurs in the epigastric region (upper abdomen) and can be described as gnawing, burning, or dull. The pain tends to worsen when the stomach is empty (hunger pains) and is relieved by eating or taking antacids. These symptoms are due to the increase in gastric acid secretion, which exacerbates the ulcer's irritation when the stomach is empty and is neutralized when food buffers the acid. Therefore, the presentation described is consistent with peptic ulcer disease (PUD).
Choice C Reason:
Esophagitis is incorrect. Esophagitis is inflammation of the esophagus and may present with symptoms such as heartburn, difficulty swallowing, or chest pain behind the breastbone. However, the symptoms described, particularly the worsening of pain when hungry and improvement after eating, are not typical of esophagitis.
Choice D Reason:
Gastroesophageal reflux (GERD) is incorrect. While gastroesophageal reflux disease (GERD) can cause epigastric discomfort or heartburn, the symptoms described in the scenario are more indicative of pain related to hunger and relief after eating, which is more characteristic of peptic ulcer disease (PUD). Additionally, GERD symptoms are typically worsened by eating, lying down, or bending over, rather than improved.
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