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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Nonadherent dressing: Nonadherent dressings are suitable for small skin tears in older adult clients because they prevent the dressing from sticking to the wound bed, minimizing trauma during dressing changes.
B. Paste: Paste dressings are typically used for wound packing or for managing exuding wounds, not for small skin tears.
C. Moist, sterile gauze: While moist, sterile gauze can be used for wound dressings, it may adhere to the wound bed, causing further trauma during dressing changes.
D. Duoderm: Duoderm is a type of hydrocolloid dressing used for moderate to heavily exuding wounds, not for small skin tears.
Correct Answer is A
Explanation
A. Signs of infection: Older adults may have compromised immune systems and are more susceptible to infections. During dressing changes, the nurse should assess for signs of infection such as increased redness, swelling, warmth, drainage, or foul odor, which could indicate an infection at the wound site.
B. Skin color changes: While changes in skin color can be indicative of various skin conditions or circulation problems, assessing for signs of infection is more pertinent during dressing changes to prevent and manage complications.
C. Decreased pain levels: Older adults may have altered pain perception due to age-related changes or comorbidities. However, assessing for signs of infection takes priority during dressing changes to ensure timely intervention if infection is present.
D. Changes in blood pressure: Changes in blood pressure may be relevant in certain clinical contexts but are not specifically related to performing dressing changes in older clients.
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