When assessing a client's skin, which finding should the nurse report to the healthcare provider?

Large, flat, dark red irregular area on the neck.

Multiple silver striae on the abdomen.

Bluish discoloration of the nailbeds.

Multiple yellow lesions with a grainy surface.

Answer and Explanation

The Correct Answer is A

A.   This finding is most concerning as it could indicate a melanoma, a type of skin cancer that is highly aggressive and potentially fatal. The characteristics of the lesion - large, flat, dark red, irregular - are consistent with a melanoma.
B.   Striae are stretch marks, often caused by rapid weight gain or pregnancy. While they can be unsightly, they are generally not a cause for concern.
C.   Bluish discoloration of the nailbeds can be a sign of cyanosis, which may indicate a lack of oxygen in the blood. However, it could also be caused by other factors such as cold temperatures or poor circulation. While this finding should be investigated further, it is not as urgent as a large, irregular, dark red area on the neck.
D.   These lesions could be xanthelasmas, which are yellow, fatty deposits often associated with high cholesterol levels. While they are not dangerous, they can be a sign of underlying health issues and should be discussed with a healthcare provider.

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Correct Answer is B

Explanation

A. Skin elasticity is assessed by pinching the skin to see how quickly it returns to its normal position, which is often done to evaluate hydration status or the presence of dehydration. While skin elasticity is an important overall assessment of skin health, it is not directly related to the assessment of erythema.
B. Palpating the erythematous area for warmth and swelling is a crucial follow-up assessment. Erythema (redness of the skin) can be a sign of inflammation or infection, and the presence of warmth and swelling can help determine if the area is inflamed or if there might be an underlying infection.
C. Oxygen saturation measurements assess the level of oxygen in the blood, typically using a pulse oximeter. While oxygen saturation is important for assessing overall respiratory and circulatory health, it is not directly related to evaluating the cause or characteristics of erythema. Therefore, this would not be the most relevant follow-up assessment for a red area on the skin.
D. Observing the appearance of the nailbeds can provide information about overall circulation and oxygenation, but it is not directly related to assessing a localized area of erythema on the skin. Changes in the nailbeds can indicate systemic conditions but would not provide specific information about the erythematous area in question.

A. “Move closer and place a hand on the client's shoulder to demonstrate concern”. B. “Ignore the angry outburst and continue with the history questions”. C. "You sound angry. Would you like to tell me about it?" D. "I am sorry you feel that way. Perhaps you'd like to return when you have more time."

Correct Answer is C

Explanation

A. While physical touch, such as placing a hand on the client’s shoulder, can sometimes be reassuring, it might not always be appropriate or welcomed, especially if the client is already expressing frustration or anger. It’s important to assess the client's comfort with physical contact before proceeding with such gestures.
B. Ignoring the client's angry outburst is not advisable because it fails to acknowledge the client’s feelings and may escalate their frustration. Addressing emotional responses is crucial in maintaining a therapeutic relationship and ensuring that the client feels heard and respected.
C. This response is the best choice because it acknowledges the client’s emotional state and invites them to share their feelings. By addressing the client's anger directly and expressing a willingness to listen, the nurse helps to validate the client’s emotions and opens the door for a more productive dialogue.
D. While this response acknowledges the client's feelings, it might come across as dismissive of their immediate needs and could imply that their concerns are not worth addressing at this time. It also does not actively engage with the client's emotions or attempt to resolve the frustration.

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When assessing a client's skin, which finding should the nurse report to the healthcare provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When inspecting a client's skin, the nurse observes an area of erythema on the arm. Which follow- up assessment should the nurse complete?

Correct Answer is B

Explanation

While the nurse is taking a health history, the client announces, "I don't have time for this. This is a waste of time. I need treatment." Which response is best for the nurse to provide?

Correct Answer is C

Explanation

When assessing a client's skin, which finding should the nurse report to the healthcare provider?

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