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

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A reason:

Sodium 140 mEq/L is incorrect because it falls within the normal range (135-145 mEq/L).

Choice B reason:

A potassium level of 5.8 mEq/L is appropriate because it is above the normal range (typically around 3.5-5.0 mEq/L). Elevated potassium levels, known as hyperkalaemia, can lead to serious cardiac disturbances, including arrhythmias or even cardiac arrest. It is important to notify the healthcare provider promptly so that appropriate interventions can be initiated to address the high potassium level.

Choice C reason:

Calcium 9.6 mg/dL is incorrect because it is within the normal range (8.5-10.5 mg/dL).

Choice D reason:

Magnesium 1.9 mEq/L is incorrect because it is within the normal range (1.5-2.5 mEq/L).

A. Supplemental oxygen supplies B. Limb restraints C. Oral suction equipment D. Oral airway E. Blood glucose monitor

Correct Answer is ["A","C","E"]

Explanation

Choice A reason:
Supplemental oxygen supplies are correct. Seizures can sometimes cause a decrease in oxygen levels, so having supplemental oxygen available can help support the client's respiratory needs.
Choice B reason:
Limb restraints are incorrect. Limb restraints are not typically used for seizure precautions as they can be dangerous and restrict the client's movement, potentially causing harm during a seizure.
Choice C reason:
Oral suction equipment is correct. Seizures can be associated with excessive saliva or potential vomiting, so having oral suction equipment ready can help clear the airway if necessary.
Choice D reason:
The oral airway is incorrect. Inserting an oral airway is not a standard part of seizure precautions and should only be used by healthcare professionals with proper training.
Choice E reason:
The blood glucose monitor is correct. Monitoring blood glucose levels can be important, especially if the client takes antiepileptic medications that may affect blood sugar levels.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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