A nurse has completed the client's initial assessment and is preparing to identify abnormal data and the client's strengths. Which of the following is required to successfully complete this phase of the nursing process?

Understanding of the referral process.

Recognition of the client's medical prognosis.

Drawing inferences about the client.

Knowledge of anatomy and physiology.

Answer and Explanation

The Correct Answer is C

A. Understanding the referral process is important for coordinating care but is not required to identify abnormal data and client strengths.
B. While knowing the medical prognosis can provide context, the nursing process focuses on holistic client assessment rather than medical diagnosis.
C. Drawing inferences about the client is correct because analyzing the collected data allows the nurse to recognize patterns, identify potential health problems, and determine the client’s strengths.
D. Knowledge of anatomy and physiology is valuable, but interpretation and clinical judgment (drawing inferences) are crucial for identifying abnormal data.

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Correct Answer is B

Explanation

A. A solid, dark brown color alone is not necessarily indicative of melanoma. Melanomas often have multiple colors, including black, brown, blue, or red.
B. Asymmetric, irregular borders is correct. Melanoma lesions are often asymmetrical, with irregular, poorly defined borders. They also tend to have varied pigmentation and may change over time. The ABCDE rule (Asymmetry, Border irregularity, Color variation, Diameter >6mm, Evolution) is used to assess suspicious moles.
C. Flat with silvery scales describes psoriasis, not melanoma.
D. A diameter of 3 mm is smaller than the typical >6 mm size seen in melanoma.

A. Client is experiencing a fluid deficit. B. Adventitious sounds are present. C. Hyperinflation of the lungs. D. Client has a pectus carinatum.

Correct Answer is C

Explanation

A. A fluid deficit may cause tachycardia and hypotension, but it does not directly cause diminished lung sounds.
B. Adventitious sounds (wheezes, crackles, rhonchi, etc.) are absent in this case. Diminished breath sounds suggest poor airflow, not abnormal sounds.
C. Hyperinflation of the lungs is correct. In conditions like chronic obstructive pulmonary disease (COPD) or emphysema, lung expansion is limited, leading to diminished breath sounds in all lung fields due to air trapping. The oxygen saturation of 92% is consistent with chronic lung disease.
D. Pectus carinatum (protrusion of the sternum) is a congenital deformity that does not cause diminished breath sounds.

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A nurse has completed the client's initial assessment and is preparing to identify abnormal data and the client's strengths. Which of the following is required to successfully complete this phase of the nursing process?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client has sought care because they are concerned that a mole on the scalp may be skin cancer. Which finding would the nurse identify as being most suggestive of melanoma?

Correct Answer is B

Explanation

Correct Answer is C

Explanation

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