While assessing a client, the nurse notices that the client's legs are asymmetrical. Which additional physical data should the nurse collect?

Perform passive range of motion and compare the findings.

Compare measured circumferences of each extremity joint.

Instruct client to walk across room and observe the gait.

Measure the length of each leg and document the findings.

Answer and Explanation

The Correct Answer is D

Choice A Reason:
Performing passive range of motion and compare the findings is inappropriate. While assessing passive range of motion can provide information about joint mobility and flexibility, it may not directly address the asymmetry observed in the legs. Range of motion assessment is more relevant for evaluating joint function and flexibility rather than leg length asymmetry.
Choice B Reason:
Comparing measured circumferences of each extremity joint is inappropriate. Measuring circumferences of extremity joints may help identify differences in muscle mass or swelling, but it may not directly address the asymmetrical leg length observed. Circumference measurements are more relevant for assessing muscle bulk or detecting signs of edema rather than leg length asymmetry.
Choice C Reason:
Instructing client to walk across the room and observe the gait is inappropriate. Observing the client's gait can provide valuable information about their walking pattern and any abnormalities in movement. While an abnormal gait may be associated with leg length asymmetry, directly measuring leg length would provide more precise data for evaluation.
Choice D Reason:
Measuring the length of each leg and document the findings is appropriate. Measuring the length of each leg can help identify any significant differences in leg length, which could be contributing to the asymmetry observed. Leg length discrepancy can result from various musculoskeletal conditions such as scoliosis, hip dysplasia, or unequal growth rates. Documenting the findings allows for accurate tracking of changes over time and provides important information for healthcare providers to determine appropriate interventions, such as orthotic devices or physical therapy.

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

Explanation

Choice A Reason:
Macule is incorrect. A macule is a flat, discolored spot on the skin that is less than 1 centimeter in diameter. It does not contain fluid; instead, it represents a change in the color of the skin, such as a freckle or a flat mole. Macules are not filled with fluid; they are characterized by alterations in skin pigmentation without any elevation or depression.
Choice B Reason:
Papule is incorrect. A papule is a small, raised bump on the skin that is less than 1 centimeter in diameter. Papules do not contain fluid; instead, they result from localized cellular infiltration, inflammation, or proliferation in the skin layers. Examples of papules include acne lesions and insect bites.
Choice C Reason:
Wheal is correct. A wheal is a raised area of skin that is typically reddened and accompanied by itching. It contains fluid and is often associated with allergic reactions, insect bites, or hives.
Choice D Reason:
Vesicle is correct. A vesicle is a small, fluid-filled blister that appears on the skin. It contains clear fluid and can be caused by various factors such as infection, allergic reactions, or friction.
Choice E Reason:
Nodule is incorrect. A nodule is a solid, raised bump on the skin that is larger than 1 centimeter in diameter and extends into deeper layers of the skin. Similar to papules, nodules do not contain fluid; they are composed of tissue, such as fat, fibrous tissue, or tumors. Examples of nodules include lipomas and dermatofibromas.
Choice F Reason:
Pustule is correct. A pustule is a small, pus-filled blister that appears on the skin. It contains purulent fluid (pus) and is often associated with bacterial infections such as acne or folliculitis.

A. Splint the affected joint. B. Encourage fluid intake. C. Increase Intake of red meat. D. Measure urine output.

Correct Answer is B

Explanation

Choice A Reason:
Splint the affected joint is inappropriate action. While splinting may help stabilize the joint and reduce movement, it may not directly address the underlying cause of the symptoms, which is9levated uric acid levels leading to gout. Additionally, splinting may further restrict range of motion and exacerbate discomfort.
Choice B Reason:
Encouraging fluid intake is appropriate action. Encouraging fluid intake, particularly water, is beneficial for individuals experiencing a gout flare-up. Adequate hydration helps to dilute uric acid in the bloodstream and promote its excretion through urine, which can help alleviate symptoms and prevent further flare-ups. Therefore, option B is the most appropriate action for the nurse to advise the client in this situation.
Choice C Reason:
Increasing intake of red meat is inappropriate action. Red meat is high in purines, which can contribute to elevated uric acid levels and increase the risk of gout flare-ups. Therefore, increasing intake of red meat would not be advisable for someone experiencing gout symptoms. In fact, dietary modifications often involve reducing intake of purine-rich foods like red meat to help manage gout.
Choice D Reason:
Measuring urine output is inappropriate action. While monitoring urine output is important for overall hydration status, it may not be the most immediate or relevant action in this situation. The priority in managing a gout flare-up is to address the underlying cause by promoting uric acid excretion through adequate hydration, rather than solely focusing on measuring urine output.

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While assessing a client, the nurse notices that the client's legs are asymmetrical. Which additional physical data should the nurse collect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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.

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

Explanation

The nurse examines a client's right great toe. The joint is red, edematous, and very painful with limited range of motion. The client's serum uric acid levels are elevated. Which action should the nurse tell the client to make?

Correct Answer is B

Explanation

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