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Skin Assessment

Highlight the abnormal findings that the nurse should be concerned about. Select all that apply.

A 40-year-old woman reports a change in mole size, accompanied by color changes, itching, burning, and bleeding over the past month. She has a dark complexion and has no family history of skin cancer, but she has had many blistering sunburns in the past.

change in mole size

color changes

itching

burning

bleeding

has had many blistering sunburns in the past

dark complexion

no family history of skin cancer

Answer and Explanation

The Correct Answer is ["A","B","C","D","E"]

A change in the size of a mole is a significant red flag and should be concerning for potential skin cancer, particularly melanoma. A mole that enlarges over time, especially if it changes size rapidly, can indicate the development of malignant melanoma.

Color changes in a mole, such as darkening, lightening, or developing multiple colors, should raise concern for melanoma. Melanomas often present with uneven pigmentation, where the mole may become more than one color, such as black, blue, red, or brown. This change in color is abnormal and requires further investigation.

Itching and burning are abnormal symptoms associated with skin lesions and can be indicative of skin cancer. These sensations can occur when the skin becomes irritated or inflamed due to a growing malignancy such as melanoma.

Bleeding from a mole is a red flag and is concerning for skin cancer, especially melanoma. A mole that bleeds or oozes may be ulcerating or eroding, which are signs of more advanced skin cancer.

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Correct Answer is B

Explanation

A. Severe obesity may not affect skin turgor but may cause other skin-related issues like stretching.
B. Severe dehydration is the most likely cause of decreased skin turgor, as dehydration reduces the amount of interstitial fluid, causing the skin to lose elasticity.
C. Connective tissue disorders such as scleroderma may affect skin appearance, but they typically cause hardening rather than decreased turgor.
D. Childhood growth spurts generally do not affect skin turgor unless other conditions are present, such as dehydration or malnutrition.

A. Pneumococcal vaccine B. Level of consciousness C. Influenza vaccine D. Health history E. Fluid intake F. Age G. Smoking history

Correct Answer is ["B","D","E","F"]

Explanation

A. The client has not received the pneumococcal vaccine, but pneumococcal vaccination would help prevent pneumonia, particularly from Streptococcus pneumoniae. However, because the client has nothad the vaccine, this option would be a risk factor for pneumonia, but it is not an immediate concern in terms of assessing the current risks in their medical record.
B. The client appears lethargic and has difficulty answering questions due to shortness of breath, which suggests a decrease in the level of consciousness. Decreased mental status or level of consciousness increases the risk of aspiration, which can lead to pneumonia. For example, an altered level of consciousness makes it harder for patients to protect their airways (e.g., coughing or swallowing properly), which may increase the risk of aspiration and subsequent infection.
C. The client has not received the influenza vaccine, which does increase the risk of contracting
pneumonia, especially if the person develops influenza. However, the patient’s primary issue is likely already in progress, so this is another unvaccinated status contributing to risk rather than an immediate finding.
D. The client’s medical history is notable for no significant conditions other than the acute issue at hand. However, the lack of a pneumococcal vaccine (despite being at higher risk due to age) and not receiving the annual influenza vaccination can contribute to the development of pneumonia. Pneumonia is more common in individuals who do not receive these vaccines, as they provide protection against common respiratory pathogens, including Streptococcus pneumoniae and influenza viruses.
E. The client reports decreased fluid intake over the past 24 hours due to a sore throat, which increases the risk of dehydration. Dehydration can lead to thicker mucus, making it more difficult to clear respiratory secretions. This increases the likelihood of bacterial growth and the development of pneumonia.
F. The client is 70 years old, which places them at higher risk for pneumonia. Older adults have a weakened immune system, and their respiratory function may not be as effective as in younger individuals, making it easier for infections such as pneumonia to take hold. Age is a significant risk factor for more severe respiratory infections.
G. There is no mention of smoking history in the social history provided, so it cannot be included as a risk factor for pneumonia in this case. Smoking is a known risk factor for respiratory infections, but since it isn’t specified here, we cannot assume it is relevant.

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Naxlex Comprehensive Predictor Exams

The nurse has discovered decreased skin turgor in a patient and knows that this finding is expected in which condition?

Correct Answer is B

Explanation

A nurse in an emergency department (ED) is admitting a client. Exhibits Select 4 findings in the client's medical record that place them at risk for pneumonia.

Correct Answer is ["B","D","E","F"]

Explanation

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