The nurse is preparing to conduct a physical assessment on a client who appears uncomfortable and slightly anxious. Which action is the most appropriate for the nurse to take?

Recommend a psychiatric consult

Proceed with the exam by completing invasive aspects first.

Stay with the client at all times to provide assistance.

Use a relaxed manner and reassure the client as necessary.

Answer and Explanation

The Correct Answer is D

A. Recommending a psychiatric consult is premature and not appropriate for routine anxiety during an assessment.

B. Starting with invasive aspects may increase the client's anxiety. Instead, the nurse should ease the client into the exam.

C. Staying with the client at all times may not be necessary and could make the client feel more uncomfortable.

D. Using a relaxed manner and reassuring the client can help reduce anxiety and make the physical assessment more comfortable.

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Free Nursing Study Resources

Correct Answer is ["B","C","E"]

Explanation

A. Numbness in the arm is not directly linked to skin cancer risk.

B. Outdoor occupations and recreational activities with a history of blistering sunburns increase the risk of skin cancer due to excessive sun exposure.

C. Fair skin, light eyes, and light hair increase susceptibility to skin cancer, especially with UV exposure.

D. Working in a beauty salon is not associated with a higher risk of skin cancer.

E. Smoking is linked to an increased risk of squamous cell carcinoma, a type of skin cancer.

A. Stage III B. unstageable C. necrotic stage I D. stage II

Correct Answer is B

Explanation

A. Stage III pressure ulcers are characterized by full-thickness skin loss that extends into the subcutaneous tissue layer but does not involve underlying muscle or bone. The ulcer appears as a deep crater, and there may be damage to the surrounding tissue.
B. The above image depicts an Unstageable pressure ulcers since the base of the ulcer is covered by slough in the wound bed.
C. The term 'necrotic stage I' is not typically used in the staging of pressure ulcers. Necrosis refers to dead tissue, which is not present in a Stage I pressure ulcer. Stage I ulcers are characterized by intact skin with non-blanchable redness of a localized area usually over a bony prominence.

D. Stage II pressure ulcers involve partial-thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed or as an intact or ruptured blister. The ulcer is painful and may appear as a shiny or dry shallow ulcer without slough or bruising.

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The nurse is preparing to conduct a physical assessment on a client who appears uncomfortable and slightly anxious. Which action is the most appropriate for the nurse to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a group of clients in the outpatient facility. Which clients are at risk for developing skin cancer? Select three options that place a client at risk for skin cancer

Correct Answer is ["B","C","E"]

Explanation

The nurse is admitting a client to the medical-surgical unit and notes the skin breakdown shown in the diagram. How should the nurse document the finding?

Correct Answer is B

Explanation

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