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 C

Explanation

Choice A reason:
A personal trainer working with a client who has HIV is at low risk for contracting the virus. HIV is not transmitted through casual contact, sweat, or saliva. The risk would increase only if there were exposure to blood or other body fluids through an open wound or mucous membrane.

Choice B reason:
An occupational therapist working with a client who has HIV also has a low risk of contracting the virus. Similar to a personal trainer, unless there is direct exposure to blood or body fluids, the transmission risk is minimal.

Choice C reason:
A phlebotomist who collects blood from clients who have HIV is at the greatest risk among the listed individuals. Phlebotomists are healthcare professionals who are frequently exposed to blood, which is a bodily fluid that can transmit HIV if proper precautions are not taken.

Choice D reason:
A nurse who collects urine samples is at a lower risk compared to a phlebotomist. HIV is not typically transmitted through urine unless it contains blood. However, the risk is still present if there is exposure to blood-contaminated urine through cuts or mucous membranes.

A. A client who has type 2 diabetes mellitus with a blood glucose level of 120 mg/dL (normal range: 74-106 mg/dL). B. A client who has diabetes insipidus with an intake of 1,500 mL and an output of 1,600 mL in 24 hours. C. A client who has Graves' disease with a heart rate of 100/min and reports tremors. D. A client who has had a left-sided stroke reports a severe headache and is manifesting confusion.

Correct Answer is D

Explanation

Choice A reason:
While a blood glucose level of 120 mg/dL is slightly above the normal range, it is not typically considered an emergency for a client with type 2 diabetes mellitus. This client would require monitoring and potential adjustment of their diabetes management plan, but it does not necessitate immediate assessment.

Choice B reason:
For a client with diabetes insipidus, an intake of 1,500 mL and an output of 1,600 mL in 24 hours is within expected parameters, considering the condition's characteristic polyuria and polydipsia. This client would need ongoing monitoring to maintain fluid balance but is not the highest priority for immediate assessment.

Choice C reason:
A heart rate of 100/min and tremors in a client with Graves' disease could indicate that their condition is not well-controlled. However, these symptoms are not as acutely concerning as those of a stroke and would be addressed after more urgent needs are met.

Choice D reason:
A client who has had a left-sided stroke and reports a severe headache and confusion is exhibiting signs of a possible acute neurological change or complication, such as increased intracranial pressure or hemorrhage. This client requires immediate assessment and intervention due to the potential for rapid deterioration and life-threatening complications.

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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

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Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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