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: Medication teaching concerning thyroid hormones is not directly related to the care of a client with pheochromocytoma. Pheochromocytoma primarily involves the adrenal glands and excessive secretion of catecholamines.

Choice B: Referral to a hospice is not a relevant goal for a client diagnosed with pheochromocytoma. Hospice care is typically provided for clients with advanced, life- limiting illnesses, and pheochromocytoma can often be treated or managed.

Choice C: Psychological counseling to address body image changes is not the primary goal for a client with pheochromocytoma. While psychological support may be beneficial, the primary focus should be on addressing the physiological effects and treatment of pheochromocytoma.

Choice D: Preoperative and postoperative teaching for adrenalectomy is the most relevant goal for a client with pheochromocytoma. Surgical removal of the tumor (adrenalectomy) is the primary treatment for pheochromocytoma, and education about the procedure, preparation, and postoperative care is essential to ensure a successful outcome.

A. Instruct the client to decrease number of cigarettes smoked daily. B. Discuss changing eating habits with a goal of losing 2 pounds (1 kg) per week. C. Encourage other family members to be tested for diabetes mellitus. D. Determine the client's feelings about being diagnosed with a chronic disease.

Correct Answer is B

Explanation

Choice A: This is important for the client's overall health but is not the most immediate priority in managing diabetes.

Choice B: The most important intervention for this client is to address lifestyle factors that contribute to diabetes and overall health. Weight loss and dietary changes are key components of managing type 2 diabetes. The client's weight is significantly above a healthy range, and losing 2 pounds (1 kg) per week is a reasonable and safe goal.

Choice C: Encouraging family members to be tested for diabetes is relevant but does not directly address the client's own management of the condition.

Choice D: Determining the client's feelings about the diagnosis is important for emotional support but does not directly address the client's physical health and diabetes management.

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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

When the nurse is designing a plan of care for a client diagnosed with pheochromocytoma, a goal statement should be prepared that relates to which topic?

Correct Answer is D

Explanation

Correct Answer is B

Explanation

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