A nurse is assessing the skin of a client who has worked outdoors for the past 20 years. Which of the following findings is the nurse's priority?
Skin tags noted in the neck region
A change in appearance of a mole on the shoulder
Atrophic wart on the left index finger
A flat, nonpalpable, discolored area of skin on the trunk
The Correct Answer is B
Choice A reason:
Skin tags noted in the neck region: Skin tags are generally benign and not typically a cause for immediate concern. While they can be removed if desired, they are not as urgent as assessing potential changes in moles for skin cancer.
Choice B reason:
A change in appearance of a mole on the shoulder is the appropriate answer. The nurse's priority should be a change in the appearance of a mole on the shoulder. Changes in the colour, size, shape, or texture of a mole can indicate potential skin cancer, especially malignant melanoma. Timely assessment and appropriate follow-up are crucial to catch any skin cancer early and ensure effective treatment.
Choice C reason:
The atrophic wart on the left index finger is incorrect. An atrophic wart is a benign skin condition and is not typically associated with skin cancer or immediate danger. It may not require urgent assessment.
Choice D reason:
A flat, nonpalpable, discoloured area of skin on the trunk: While any change in skin appearance should be assessed, a nonpalpable, discoloured area may not present an immediate concern unless it shows signs of growth, change, or other concerning features.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason
The client has an implanted defibrillator is the correct answer. Magnet therapy involves the use of magnets to alleviate pain and promote healing. However, it is contraindicated for individuals with implanted electronic devices, such as pacemakers or defibrillators, as the magnetic field could potentially interfere with the functioning of these devices. The safety of using magnet therapy with implanted devices has not been established, and caution is advised.
Choice B reason:
Allergic to penicillin is incorrect. Allergies to penicillin or other substances are not related to the use of magnet therapy.
Choice C reason:
The history of alcohol use disorder is incorrect. A history of alcohol use disorder does not directly contraindicate the use of magnet therapy.
Choice D reason:
The prescription for metoprolol is incorrect. Metoprolol is a common medication used to treat various conditions, including hypertension and certain heart conditions. It is not a contraindication for magnet therapy.
Correct Answer is B
Explanation
Choice A reason:
Performing percussion over the lower back: While percussion is part of the postural drainage technique, the specific areas to be percussed depend on the client's individualized care plan, which is based on the location of lung segments affected by cystic fibrosis. The nurse should follow the care plan and target the appropriate lung segments for percussion.
Choice B reason:
Covering the area of percussion with a towel is correct. When performing postural drainage with percussion and vibration for a client with cystic fibrosis, it is important to cover the area of percussion with a towel. This helps protect the client's skin and prevent discomfort or injury during the procedure. The towel acts as a barrier between the nurse's hand and the client's skin, allowing for effective percussion while minimizing friction and pressure
Choice Creason:
Scheduling postural drainage after meals: Postural drainage is ideally performed before meals or at least 1-2 hours after meals to avoid potential discomfort or vomiting due to the positioning and movement during the procedure.
Choice Dreason:
Instructing the client to exhale quickly during vibration: Vibration is typically performed during the client's exhalation phase, but the instruction should focus on slow, controlled exhalation rather than quick exhalation.
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