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 D

Explanation

Choice A: A mechanical soft diet may still require some degree of chewing, which may be difficult for a client with no teeth. A pureed diet would be a more appropriate choice.

Choice B: A soft low-residue diet may include soft foods that require chewing, which could be challenging for a client with no teeth.

Choice C: A full liquid diet consists of liquids and foods that are in liquid form at room temperature, which may not provide adequate nutrition for the client.

Choice D: A pureed diet involves blending foods to a smooth consistency, making them suitable for clients with no teeth or difficulty chewing. It would be the most appropriate choice.

A. Encourage the UAP to demonstrate the effective use of the incentive spirometer to the client. B. Schedule time later in the morning to review the use of the incentive spirometer with the client. C. Ask the practical nurse assigned to care for the client to review the use of the spirometer with the client. D. Advise the UAP that the respiratory therapist is responsible to supervise the client's use of the spirometer.

Correct Answer is C

Explanation

A. Encouraging the UAP to demonstrate the effective use of the incentive spirometer may not be appropriate since the UAP may not have the necessary training or expertise to provide proper instruction.
B. Scheduling time later to review the use of the spirometer does not address the immediate need for the client to understand how to use it effectively and may delay important interventions for respiratory health.
C. Asking the practical nurse assigned to care for the client to review the use of the spirometer ensures that the client receives accurate and professional guidance. The practical nurse has the training to properly instruct the client on the effective use of the incentive spirometer, which is crucial for preventing complications like atelectasis.
D. Advising the UAP that the respiratory therapist is responsible for supervising the client's use of the spirometer does not empower the UAP to take action and does not address the immediate concern regarding the client’s ineffective use.

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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

During the admission assessment, an older male client who has no teeth tells the nurse that he cannot find his dentures at home. His dietary prescription is a regular diet. What diet request should the nurse recommend for this client?

Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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