What data collected during an integumentary assessment should cause the nurse to be concerned that a client is at risk for the development of skin cancer? (Select all that apply.)
Age 55 years
Yellow palms of the hands
Light-colored hair
Actinic keratosis on face
Poor skin turgor
Correct Answer : A,C,D
A) Age 55 years:
Advancing age is a risk factor for skin cancer. As individuals age, the cumulative exposure to UV radiation increases, and the skin's ability to repair damage decreases, leading to a higher risk of skin cancer.
B) Yellow palms of the hands:
Yellow palms are typically associated with conditions like carotenemia or jaundice, not skin cancer. This symptom does not indicate an increased risk of developing skin cancer.
C) Light-colored hair:
Individuals with light-colored hair, especially those with fair skin and light eyes, are at higher risk for skin cancer. They often have less melanin, which provides some protection against UV radiation, increasing their susceptibility to damage from the sun.
D) Actinic keratosis on face:
Actinic keratosis is a precancerous skin lesion caused by long-term sun exposure. It is considered a significant risk factor for developing squamous cell carcinoma, a type of skin cancer. Presence of actinic keratosis should prompt careful monitoring and possibly treatment.
E) Poor skin turgor:
Poor skin turgor typically indicates dehydration or aging but is not directly related to an increased risk of skin cancer. It is more of a general indicator of skin and overall health rather than a specific risk factor for cancer.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. To prevent further dehydration:
While preventing dehydration is important, it is not the primary reason for bringing a cup of water when assessing the thyroid gland. Dehydration is addressed through overall fluid management rather than during a specific thyroid exam.
B. To assist the client to feel more comfortable:
Providing comfort is essential, but bringing a cup of water specifically for comfort during a thyroid exam is not typically necessary. The primary focus of the water in this context is related to the assessment process.
C. To observe the movement of the thyroid gland:
Observing the movement of the thyroid gland during swallowing can help the nurse assess for abnormalities. Having the client drink water allows the nurse to observe the thyroid gland's movement, which can indicate the presence of goiters, nodules, or other irregularities.
D. To promote the nurse-client relationship:
Promoting a good nurse-client relationship is always beneficial, but bringing a cup of water for this specific purpose is not relevant to the physical assessment of the thyroid gland. The water's main purpose is to facilitate the physical examination process.
Correct Answer is C
Explanation
(a) Inquire about family history of headaches:
While understanding the client's family history of headaches can be important for a comprehensive assessment, it is not the immediate priority. The description of "the worst headache" ever experienced could indicate a serious condition that needs urgent attention.
(b) Review the client's medical record:
Reviewing the client's medical record provides valuable information about their history and potential underlying conditions. However, given the severity of the reported headache, it is crucial to perform a more immediate physical assessment to rule out life-threatening conditions.
(c) Assess the client's blood pressure:
Assessing the client's blood pressure is a critical initial action. A severe headache can be a symptom of hypertensive crisis, stroke, or other serious conditions. High blood pressure could provide an immediate clue to the severity and cause of the headache, allowing for quicker intervention.
(d) Provide medication for pain relief:
Providing pain relief is important, but it should not be the first action without determining the cause of the headache. Administering medication without assessing the client's condition could mask symptoms of a potentially serious underlying issue such as a stroke or hypertensive emergency.
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