During the skin assessment of a client, the nurse observes a skin lesion that is elevated, round, and filled with serum. Identify the type of lesion.

Choice A rationale

Palpating the client's skin for moisture, temperature, and texture is essential in wound management. This allows the nurse to assess for signs of infection or inflammation, which can affect the wound healing process. Moisture can indicate excessive drainage or sweating that might macerate the skin, while changes in temperature and texture can signify infection or poor blood flow.

Choice B rationale

While asking the client whether the wound bed or surrounding skin itches may provide some information about the client's comfort, it is not a primary intervention for wound management. Itching can be a sign of healing or irritation, but it does not provide direct information on the wound's condition.

Choice C rationale

Measuring and assessing the wound bed, size, edges, and margins are critical steps in wound management. This helps to determine the progression of healing, the presence of necrotic tissue, and any changes in the wound over time. Accurate measurement and documentation are essential for developing an appropriate care plan.

Choice D rationale

Evaluating the client's level of pain using a numeric value pain scale is important in wound management. Pain can indicate underlying issues such as infection, poor perfusion, or neuropathy. Assessing pain helps guide interventions to provide comfort and address any complications that may arise.

Choice E rationale

Reviewing the client's prothrombin time test and international normalized ratio is not a standard intervention for wound management. These tests are more relevant to assessing the client's coagulation status, which may be important for surgical or anticoagulant therapy but not directly for wound care.

Choice A rationale

Encouraging adequate water intake by the client is a general recommendation for maintaining hydration but does not address the client's fear of the EEG procedure, nor does it dispel misconceptions about electrical shock.

Choice B rationale

Distracting the client's attention from the test may provide temporary relief from anxiety but does not address or correct the client's specific fear related to being electrocuted during the EEG procedure.

Choice C rationale

Informing the client that they will not experience any electrical shock is crucial in dispelling the client's fear. An EEG measures electrical activity in the brain using sensors on the scalp; it does not involve delivering electrical shocks to the client.

Choice D rationale

Informing the client that they will experience only mild electrical shock is incorrect and could increase the client's fear. An EEG does not administer any form of electrical shock to the client; it is a non-invasive and painless procedure.