A nurse is admitting a client who has a partial hearing loss.
Which of the following is the priority action by the nurse?

Rephrase statements the client does not hear.

Determine if the client uses hearing aids.

Speak using his usual tone of voice and directly in front of the client.

Use hand gestures to communicate.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Rephrasing statements the client does not hear is helpful but not the priority action. The priority is to determine if the client uses hearing aids to ensure they can hear instructions and communication effectively.

Choice B rationale

Determining if the client uses hearing aids is the priority action. Ensuring the client has and uses their hearing aids can significantly improve communication and care.

Choice C rationale

Speaking using the usual tone of voice and directly in front of the client is important but secondary to ensuring the client has their hearing aids.

Choice D rationale

Using hand gestures to communicate can be helpful but is not the priority action. The primary focus should be on ensuring the client has their hearing aids for optimal hearing.

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Correct Answer is B

Explanation

Choice B rationale

The FLACC scale (Face, Legs, Activity, Cry, Consolability) is specifically designed for assessing pain in infants and young children who are unable to communicate their pain verbally.

Choice A rationale

The Visual Analog Scale is used for older children and adults who can understand and communicate their pain level.

Choice C rationale

The Oucher scale is used for children aged 3 to 12 years and involves matching facial expressions to a pain level.

Choice D rationale

The Faces scale is used for children aged 3 years and older who can point to a face that best represents their pain level.

A. Actinic keratosis. B. Malignant melanoma. C. Squamous cell carcinoma. D. Basal cell carcinoma.

Correct Answer is D

Explanation

Choice D rationale

Basal cell carcinoma often appears as a raised, flesh-colored lesion with pearly and waxy borders. It is the most common type of skin cancer and typically occurs in areas exposed to the sun.

Choice A rationale

Actinic keratosis is a precancerous condition that appears as rough, scaly patches on sun-exposed skin.

Choice B rationale

Malignant melanoma is a more aggressive form of skin cancer that often appears as a new, unusual growth or a change in an existing mole.

Choice C rationale

Squamous cell carcinoma typically appears as a firm, red nodule or a flat lesion with a scaly, crusted surface. .

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A nurse is admitting a client who has a partial hearing loss. Which of the following is the priority action by the nurse?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a 6-month-old infant who is postoperative following a myringotomy. Which of the following pain scales should the nurse use to determine the infant’s pain level?

Correct Answer is B

Explanation

During a routine physical examination, a nurse observes a 1-cm (0.4-in) lesion on a client’s chest. The lesion is raised and flesh-colored with pearly and waxy borders that are well defined. The nurse should recognize that this finding is suggestive of which of the following types of skin cancer?

Correct Answer is D

Explanation

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A nurse is admitting a client who has a partial hearing loss.
Which of the following is the priority action by the nurse?