During assessment of a 2-month-old infant, the nurse notices a bluish-black discoloration over the lumbosacral area. Which action should the nurse take?

Document the findings in the record.

Report possible child abuse to protective services.

Gently rub the area with skin cream to promote healing.

Ask the mother about the discoloration.

Answer and Explanation

The Correct Answer is A

A. Document the findings in the record – A bluish-black discoloration over the lumbosacral area is most likely a Mongolian spot, a benign congenital birthmark commonly seen in infants with darker skin tones. It does not require intervention, only documentation.
B. Report possible child abuse to protective services – Mongolian spots may resemble bruises, but they are not a sign of abuse. Reporting without further assessment is inappropriate.
C. Gently rub the area with skin cream to promote healing – Mongolian spots are not injuries and do not require treatment.
D. Ask the mother about the discoloration – While obtaining history is important, Mongolian spots are well-known benign findings that do not require further clarification from the parent.

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Correct Answer is C

Explanation

Choice A: Permethrin cream may cause temporary itching and skin irritation as it works to eliminate the scabies mites. Instructing the client to remove the cream immediately if pruritis occurs is not necessary; it is a common and expected side effect during treatment.

Choice B: Reapplication of permethrin is not typically done in seven days unless directed by the healthcare provider. A single application is often effective in treating scabies.

Choice C: Showering or bathing 8 to 14 hours after permethrin treatment is a common instruction to remove the cream and dead mites. This is an important part of the treatment process.

Choice D: Avoiding areas between fingers and toes during application is not necessary, as permethrin is generally safe for use on these areas. However, it should not be applied to the face or near the eyes.

A. Praise the client for the successful weight loss using the natural herbs. B. Tell the client to schedule an appointment with a healthcare provider. C. Advise the client to begin taking a multivitamin daily. D. Document the client's reason for using the herb.

Correct Answer is B

Explanation

Choice A: Praising the client for weight loss without knowing the underlying cause may not be appropriate. Rapid and unexplained weight loss can be a sign of underlying health issues.

Choice B: Advising the client to schedule an appointment with a healthcare provider is the most appropriate action. Rapid and unexplained weight loss should be evaluated by a healthcare professional to identify any potential underlying health concerns.

Choice C: Advising the client to begin taking a multivitamin daily does not address the underlying cause of the weight loss and may not be the most appropriate action.

Choice D: Documenting the client's reason for using the herb is important but should be accompanied by further evaluation and intervention by a healthcare provider due to the significant weight loss.

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During assessment of a 2-month-old infant, the nurse notices a bluish-black discoloration over the lumbosacral area. Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An adult client receives a prescription for permethrin (Acticin Cream 5%) to treat an infestation of scabies. The nurse instructs the client to massage the cream into the skin from the head to the soles of the feet, avoiding the eyes. Which additional instruction should the nurse provide?

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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