A nurse is collecting data from a client who reports finding a new skin lesion. Which of the following actions is the nurse's priority?
Document the client's history of skin allergies.
Photograph the lesion for the client's medical record.
Identify when the client first noticed the lesion.
Instruct the client on the use of daily sunscreen products.
The Correct Answer is C
A. Document the client's history of skin allergies: While important for the client's overall care, documenting the history of skin allergies is not the priority when assessing a new skin lesion.
B. Photograph the lesion for the client's medical record: Documenting the appearance of the lesion is important for the client's medical record, but it is not the priority when initially assessing the lesion.
C. Identify when the client first noticed the lesion: The priority is to gather information about the onset and characteristics of the lesion to determine its potential severity and urgency of intervention.
D. Instruct the client on the use of daily sunscreen products: While sun protection is important for skin health, it is not the priority when assessing a new skin lesion.
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Related Questions
Correct Answer is D
Explanation
A. Hand hygiene: Hand hygiene is a measure to break the chain of infection by reducing the number of microorganisms on hands. It is not a reservoir of infection.
B. Wearing personal protective equipment (PPE): PPE is used to protect healthcare workers and patients from exposure to infectious agents. It does not serve as a reservoir for infection.
C. Proper disposal of sharps: Proper disposal of sharps is important to prevent needlestick
injuries and transmission of bloodborne pathogens but does not represent a reservoir of infection.
D. A contaminated surface: A contaminated surface can serve as a reservoir for infectious agents.
Reservoirs are places where infectious agents can survive and multiply, posing a risk of transmission to susceptible individuals.
Correct Answer is A
Explanation
A. Administering analgesic medications: Analgesic medications, such as nonsteroidal anti-inflammatory drugs (NSAIDs) or opioids, can help alleviate pain associated with impaired skin integrity by reducing inflammation and blocking pain signals.
B. Performing gentle massage on the affected area: While massage can sometimes provide relief for certain types of pain, it may not be appropriate for all types of impaired skin integrity and could potentially exacerbate the condition or cause further damage.
C. Applying a heating pad to the affected area: Heat therapy may be contraindicated for certain types of impaired skin integrity, as it can increase inflammation and worsen pain. It is not
typically recommended as a primary intervention for managing pain in this context.
D. Using topical antibiotics on the affected area: Topical antibiotics are used to treat or prevent infections but are not primarily indicated for pain management associated with impaired skin
integrity.
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