Patient Data

Exhibits

During the assessment, the nurse notes that the areas are filled with a fluid-like substance.

Which of the following primary skin lesions contain fluid? Select all that apply.

Choice A Reason:
Normal mental status for age is incorrect. This choice would not be the most accurate conclusion based on the client's response. While it's possible that the client's response could be influenced by factors such as cultural background or personal interpretation, the inability to understand the metaphorical meaning of a commonly known proverb might suggest some level of cognitive impairment or difficulty with abstract thinking. Therefore, it would be premature to conclude that the client's response reflects a normal mental status for her age.
Choice B Reason:
Impaired concentration is incorrect. Impaired concentration would manifest as difficulty maintaining focus our attention during the interaction. However, the client's response doesn't suggest a lack of attention or focus. Instead, it indicates a misinterpretation of the proverb, which is more indicative of impaired thinking or difficulty understanding abstract concepts rather than impaired concentration.
Choice C Reason:
Impaired memory is incorrect. Impaired memory would typically involve difficulty recalling information or events from the past. In this scenario, the client is able to recall the phrase "Glass Houses" but demonstrates difficulty understanding its meaning. Therefore, impaired memory is not the most appropriate conclusion based on the client's response. Instead, the response suggests impaired thinking or difficulty with abstract reasoning.
Choice D Reason:
Impaired thinking is correct. The client's response indicates difficulty understanding the metaphorical meaning of the proverb "Glass Houses," which typically implies that those who live in fragile or vulnerable situations should avoid criticizing others, as they themselves are also vulnerable to criticism or judgment. Instead, the client's response focuses on the literal interpretation of the phrase, suggesting impaired thinking or difficulty grasping abstract concepts.

Choice A Reason:
Requesting diagnostic laboratory testing for the client is appropriate action. Enlargement of the thyroid gland can be indicative of various thyroid disorders, including hyperthyroidism, hypothyroidism, or thyroid nodules. Diagnostic laboratory testing, such as thyroid function tests (TFTs), thyroid antibody testing, and possibly thyroid ultrasound, can help identify the underlying cause of the thyroid enlargement. These tests can include assessments of thyroid hormone levels (T3, T4, and TSH), antibodies, and imaging studies. Requesting diagnostic laboratory testing is essential to accurately diagnose the condition and guide appropriate management and treatment.
Choice B Reason:
Obtaining a dietary consultation for nutrition teaching is inappropriate action. While nutrition can play a role in overall thyroid health, obtaining a dietary consultation for nutrition teaching is not the most immediate action to take in response to finding an enlarged thyroid gland during palpation. Dietary consultation may be considered as part of comprehensive care for thyroid disorders, but it does not address the need for further evaluation and diagnosis of the thyroid enlargement.
Choice C Reason:
Instructing the client in the need to use iodized salt is inappropriate action. While iodine deficiency can contribute to thyroid disorders, instructing the client to use iodized salt is not the most immediate action to take in response to finding an enlarged thyroid gland during palpation. Using iodized salt may help prevent iodine deficiency, but it does not address the need for further evaluation and diagnosis of the thyroid enlargement.
Choice D Reason:
Scheduling a follow-up appointment in one month is inappropriate action. While scheduling a follow-up appointment may be necessary for ongoing monitoring and management of thyroid disorders, it is not the most immediate action to take in response to finding an enlarged thyroid gland during palpation. Further evaluation and diagnostic testing should be prioritized to determine the underlying cause of the thyroid enlargement and initiate appropriate treatment.