The nurse is admitting a client who reports symptoms of dyspnea. The nurse notes edema of the upper arms, face, and neck. What is the nurse's priority assessment?
Degree of upper body vasculature observed.
Arm circumference and degree of edema.
Blood pressure and heart rate.
Peripheral sensation and movement of upper extremities.
The Correct Answer is C
A. Assessing the degree of upper body vasculature may provide some information, but it does not directly address the client's current symptoms or vital status.
B. Measuring arm circumference and evaluating the degree of edema are important for understanding the extent of swelling but do not assess the client’s hemodynamic stability or respiratory status.
C. Blood pressure and heart rate are critical assessments in this scenario, especially considering the client’s dyspnea and upper body edema. Changes in these vital signs can indicate potential respiratory distress, compromised cardiac function, or anaphylaxis, which requires immediate intervention.
D. While assessing peripheral sensation and movement is important for overall neurological function, it is not a priority in this context compared to assessing vital signs that can directly affect the client’s stability.
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Correct Answer is B
Explanation
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B. Teaching safety in the home to reduce injury and falls is the most important intervention. Clients with thrombocytopenia have a significantly increased risk of bleeding and bruising, making it essential to prevent falls and injuries that could lead to serious complications.
C. Spacing activities throughout the day can help manage fatigue, but it is not as urgent as ensuring the client is safe from injuries related to low platelet counts.
D. Frequent hand hygiene is important to prevent infections, especially in immunocompromised patients, but it does not directly address the primary concern of preventing injuries related to thrombocytopenia.
Correct Answer is D
Explanation
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B. Raised, tubular, white areas may represent benign conditions, such as skin tags or cysts, which generally do not require urgent evaluation unless symptomatic.
C. Beige, small brown spots are often benign, such as liver spots or freckles; these typically do not signal immediate concern unless there are changes in size or color.
D. An irregular shaped, blue mole with white specks raises significant concern for potential melanoma, a serious form of skin cancer; any atypical characteristics in moles warrant immediate evaluation to rule out malignancy.