What abnormal physical response should the nurse be prepared to manage after noting pallor in a client?

diarrhea

diaphoresis

fainting

vomiting

Answer and Explanation

The Correct Answer is C

(a) Diarrhea: Diarrhea is an abnormal gastrointestinal response characterized by frequent, loose, or watery stools. It can be caused by infections, medications, or underlying gastrointestinal disorders. Pallor, or paleness of the skin, typically does not directly lead to diarrhea unless there are specific underlying conditions affecting both circulation and gastrointestinal function.

(b) Diaphoresis: Diaphoresis refers to excessive sweating, which can occur due to sympathetic nervous system activation, fever, or anxiety. While diaphoresis may be associated with conditions causing increased sympathetic activity, it is not directly related to pallor, which indicates reduced blood flow to the skin.

(c) Fainting: Pallor is often a sign of decreased blood flow to the skin, indicating potential hypoperfusion. If severe, this reduced circulation can lead to fainting (syncope) due to inadequate blood supply to the brain. Therefore, after noting pallor, the nurse should be prepared to manage the client for potential fainting episodes by ensuring safety and providing appropriate interventions.

(d) Vomiting: Vomiting is the forceful expulsion of stomach contents through the mouth and can be caused by various factors such as gastrointestinal irritation, infection, or systemic illnesses. Pallor does not directly cause vomiting, although severe systemic conditions affecting circulation could potentially lead to nausea and vomiting as part of a broader clinical picture.

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Correct Answer is C

Explanation

A) Snellen chart:

The Snellen chart is used to assess distance vision, not near vision. It consists of letters or symbols arranged in rows, with the client typically asked to read from a specific distance to test visual acuity.

B) Penlight:

A penlight is primarily used to assess pupillary reactions and near vision tasks such as accommodation. It helps examine how the pupils respond to light and how well the eyes focus on near objects.

C) Magazine:

A magazine or similar reading material is commonly used to assess near vision. Clients are asked to read the text at a comfortable distance, evaluating their ability to focus on close-up objects and the clarity of their vision.

D) Ophthalmoscope:

An ophthalmoscope is used to examine the interior structures of the eye, such as the retina and optic nerve head. It is not used for assessing near vision but rather for diagnosing conditions affecting the eye's internal structures.

A. Location B. Color C. Condition of surrounding skin D. Elevation E. Distribution pattern

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

Explanation

A) Location: Documenting the exact location of lesions is crucial for monitoring changes over time, assessing potential spread or resolution, and providing accurate information for future reference. This information helps in the diagnosis and in tracking the effectiveness of treatments.

B) Color: The color of lesions can provide important clues about their nature and cause. For example, red or inflamed lesions might indicate infection or irritation, while darker lesions could suggest malignancy or chronicity. Color changes can also signify healing or worsening of the lesion.

C) Condition of surrounding skin: Noting the condition of the skin around the lesions helps assess whether there is additional inflammation, infection, or other skin conditions that may be related to the primary lesion. This provides a more comprehensive understanding of the patient’s skin health and any secondary complications.

D) Elevation: Elevation refers to whether the lesion is raised, flat, or depressed compared to the surrounding skin. This characteristic helps in identifying the type of lesion, such as a papule, plaque, or ulcer. Elevated lesions might suggest certain dermatological conditions, while depressed lesions might indicate scarring or loss of tissue.

E) Distribution pattern: The pattern of how lesions are distributed on the body can provide diagnostic clues. For example, a linear distribution might suggest contact dermatitis, while a symmetrical distribution could indicate a systemic condition. Understanding the distribution pattern helps in identifying the underlying cause and planning appropriate treatment.

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What abnormal physical response should the nurse be prepared to manage after noting pallor in a client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing to assess a client's near vision. The nurse would use which piece of equipment for the assessment?

Correct Answer is C

Explanation

After completing an integument physical examination, the nurse is documenting information concerning observed lesions. What characteristics will the nurse include in this documentation? (Select all that apply.)

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

Explanation

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