A nurse is observing a newly licensed nurse who is performing a focused skin assessment on a client who reports a skin condition. Which of the following questions by the newly licensed nurse requires intervention?

Have you had any changes in your diet?

How do you handle stress?

How does your skin condition make you feel?

Does your skin condition keep you awake at night?

Answer and Explanation

The Correct Answer is C

Choice A reason:
Asking about dietary changes is relevant to a skin assessment, as diet can influence skin health. However, this question does not require intervention unless the dietary changes are directly related to the skin condition. If the client has been advised to follow a specific diet for their skin condition, then the nurse should ensure compliance with that diet.

Choice B reason:
Understanding how a client handles stress is important because stress can exacerbate many skin conditions. This question is appropriate and does not require intervention. Stress management techniques may be beneficial for the client and could be a part of the care plan.

Choice C reason:
Inquiring about the emotional impact of a skin condition is a critical aspect of holistic care. Skin conditions can significantly affect a person's self-esteem and emotional well-being. This question is empathetic and helps the nurse understand the client's experience, thus no intervention is needed.

Choice D reason:
Sleep disturbances can be a consequence of skin conditions, especially if they involve itching or pain. This question is pertinent to the assessment and does not require intervention. The information gathered can help in formulating a comprehensive care plan that addresses the client's comfort and sleep quality.

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

Explanation

The correct answer is: a. Temperature, c. Color, d. Sensation.

Choice A: Temperature

Reason: Monitoring the temperature of the affected extremity is crucial in evaluating neurovascular status. A cool or cold extremity can indicate decreased perfusion, which may be a sign of neurovascular compromise. Normal skin temperature should be warm to the touch, indicating adequate blood flow.

Choice B: Ecchymosis

Reason: Ecchymosis, or bruising, is not a direct indicator of neurovascular status. While it can provide information about trauma or bleeding, it does not assess the functionality of nerves or blood vessels in the affected extremity.

Choice C: Color

Reason: Assessing the color of the extremity is essential. Pallor or cyanosis can indicate poor blood flow or oxygenation, which are critical signs of neurovascular impairment. Normal color should be consistent with the rest of the body, indicating good circulation.

Choice D: Sensation

Reason: Evaluating sensation helps determine if there is any nerve damage or impairment. Changes in sensation, such as numbness or tingling, can indicate neurovascular compromise. Normal sensation should be intact and symmetrical with the unaffected extremity.

Choice E: Skin Integrity

Reason: While skin integrity is important for overall wound healing and infection prevention, it is not a primary parameter for assessing neurovascular status. It does not provide direct information about blood flow or nerve function.

A. Oral temperature of 38.2°C (100.76°F) B. Output of burgundy-colored urine C. Pulse rate of 88/min D. An urge to void despite having an indwelling urinary catheter

Correct Answer is A

Explanation

Choice A reason: An elevated oral temperature of 38.2°C (100.76°F) postoperatively can indicate an infection, which is a common complication after surgical procedures. In the context of TURP, a fever could suggest a urinary tract infection or sepsis, especially if accompanied by other symptoms such as chills or an elevated white blood cell count.

Choice B reason: The output of burgundy-colored urine can be expected in the immediate postoperative period following a TURP due to bleeding. However, it should gradually lighten in color. Persistent or worsening hematuria could indicate a complication, but it is not uncommon to see some blood in the urine shortly after the procedure

Choice C reason: A pulse rate of 88/min is within the normal range (60-100 beats per minute) and is not typically indicative of a postoperative complication. It is important to consider the patient's baseline heart rate and any other symptoms they may be experiencing.

Choice D reason: Feeling an urge to void despite having an indwelling urinary catheter can occur due to bladder spasms or irritation from the catheter itself. While uncomfortable, this sensation is not uncommon after TURP and does not necessarily indicate a complication.

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A nurse is observing a newly licensed nurse who is performing a focused skin assessment on a client who reports a skin condition. Which of the following questions by the newly licensed nurse requires intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is postoperative following an open reduction internal fixation (ORIF) of a femur fracture. Which of the following parameters should the nurse include in the evaluation of the neurovascular status of the client's affected extremity? (Select all that apply.)

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

Explanation

Choice A: Temperature

Choice B: Ecchymosis

Choice C: Color

Choice D: Sensation

Choice E: Skin Integrity

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Correct Answer is A

Explanation

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