During a home visit, the nurse assesses the skin of a client with eczema who reports that an exacerbation of symptoms has occurred during the last week. Which information is most useful in determining the possible cause of the symptoms?
Corticosteroid cream was applied to eczema.
A grandson and his new dog recently visited.
Recently received an influenza immunization.
An old friend with eczema came for a visit.
The Correct Answer is B
A. While the use of corticosteroid cream is relevant to treatment, it does not indicate a new cause for symptom exacerbation.
B. The introduction of a new dog could be a potential allergen, triggering an exacerbation of the client's eczema symptoms.
C. Receiving an influenza immunization is unlikely to be related to eczema exacerbations and is not a common trigger.
D. An old friend with eczema does not present a direct cause for the current exacerbation and is less relevant to the client's current condition.
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Correct Answer is C
Explanation
A. Clear, dark amber-colored urine may indicate dehydration or concentrated urine, which does not necessarily signify improvement in liver function or treatment efficacy.
B. A prothrombin time within normal limits may indicate improved liver function; however, it is not the primary goal of the treatment plan focused on managing ascites and fluid retention in cirrhosis.
C. Decreased abdominal girth is a key indicator of progress in managing fluid retention associated with cirrhosis, as the treatment plan aims to reduce ascites through a low sodium diet and albumin infusions.
D. Improved level of consciousness is essential for overall recovery but is not the primary measure of progress related to fluid management and treatment effects in this context.
Correct Answer is A
Explanation
A. Acute pain is the most immediate and pressing problem for the client, given the reported severe flank pain. Managing pain effectively is a primary concern in nursing care, particularly for clients with renal calculi.
B. While impaired renal function is a concern with renal calculi, the acute pain takes precedence as it requires immediate intervention to enhance the client's comfort and promote better overall health.
C. The risk for aspiration is a potential issue due to nausea and vomiting; however, addressing the pain is more urgent in this scenario.
D. Nutritional deficit related to nausea is also a valid concern but is secondary to the acute pain management. The client’s immediate comfort and pain relief should be prioritized to facilitate recovery and improve overall well-being.