In which disease process should a nurse expect to see a client with the presence of pitting edema?

Liver Disease

Diabetes mellitus

End Stage Renal Disease

Colon Cancer

Answer and Explanation

The Correct Answer is A

(a) Liver Disease:

Pitting edema is commonly seen in liver disease, especially in conditions like cirrhosis. Liver disease can lead to hypoalbuminemia, where low levels of albumin in the blood cause fluid to leak into the interstitial spaces, resulting in edema. Additionally, liver disease often leads to portal hypertension, which can also contribute to the development of edema.

(b) Diabetes mellitus:

While diabetes can cause complications such as diabetic nephropathy, which may lead to fluid retention, pitting edema is not a primary symptom directly associated with diabetes mellitus. Diabetic patients may develop edema due to kidney issues, but it is not as directly associated as with liver disease.

End-stage renal disease (ESRD) can indeed cause significant fluid retention and edema, including pitting edema. The kidneys' inability to excrete excess fluid leads to its accumulation in tissues. However, the question seems to point towards liver disease, which directly leads to conditions causing pitting edema.

(d) Colon Cancer:

Colon cancer is not typically associated with pitting edema. While advanced cancer can lead to various complications, including fluid imbalances, it is not a primary cause of pitting edema. Edema related to cancer is often more localized and associated with tumor sites or treatment areas.

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Correct Answer is ["A","C","D"]

Explanation

A) Age 55 years:

Advancing age is a risk factor for skin cancer. As individuals age, the cumulative exposure to UV radiation increases, and the skin's ability to repair damage decreases, leading to a higher risk of skin cancer.

B) Yellow palms of the hands:

Yellow palms are typically associated with conditions like carotenemia or jaundice, not skin cancer. This symptom does not indicate an increased risk of developing skin cancer.

C) Light-colored hair:

Individuals with light-colored hair, especially those with fair skin and light eyes, are at higher risk for skin cancer. They often have less melanin, which provides some protection against UV radiation, increasing their susceptibility to damage from the sun.

D) Actinic keratosis on face:

Actinic keratosis is a precancerous skin lesion caused by long-term sun exposure. It is considered a significant risk factor for developing squamous cell carcinoma, a type of skin cancer. Presence of actinic keratosis should prompt careful monitoring and possibly treatment.

E) Poor skin turgor:

Poor skin turgor typically indicates dehydration or aging but is not directly related to an increased risk of skin cancer. It is more of a general indicator of skin and overall health rather than a specific risk factor for cancer.

A. Inquire about family history of headaches. B. Review the client's medical record. C. Assess the client's blood pressure. D. Provide medication for pain relief.

Correct Answer is C

Explanation

(a) Inquire about family history of headaches:

While understanding the client's family history of headaches can be important for a comprehensive assessment, it is not the immediate priority. The description of "the worst headache" ever experienced could indicate a serious condition that needs urgent attention.

(b) Review the client's medical record:

Reviewing the client's medical record provides valuable information about their history and potential underlying conditions. However, given the severity of the reported headache, it is crucial to perform a more immediate physical assessment to rule out life-threatening conditions.

Assessing the client's blood pressure is a critical initial action. A severe headache can be a symptom of hypertensive crisis, stroke, or other serious conditions. High blood pressure could provide an immediate clue to the severity and cause of the headache, allowing for quicker intervention.

(d) Provide medication for pain relief:

Providing pain relief is important, but it should not be the first action without determining the cause of the headache. Administering medication without assessing the client's condition could mask symptoms of a potentially serious underlying issue such as a stroke or hypertensive emergency.

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In which disease process should a nurse expect to see a client with the presence of pitting edema?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

What data collected during an integumentary assessment should cause the nurse to be concerned that a client is at risk for the development of skin cancer? (Select all that apply.)

Correct Answer is ["A","C","D"]

Explanation

A 57-year-old client reports, "I am having the worst headache I have ever experienced." Which action/Priority should the nurse perform next?

Correct Answer is C

Explanation

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