When caring for an older adult client, the practical nurse (PN) notices a small, black mole on the posterior aspect of the client's calf. Which action should the PN take?

Ask the healthcare provider to consult a dermatologist.

Nothing, this is a normal skin change in the older client.

Ask the client if the mole always looked this way.

Document the presence and appearance of the mole.

Answer and Explanation

The Correct Answer is C

Rationale:

A. Ask the healthcare provider to consult a dermatologist: While referral may be necessary if the mole appears suspicious, the initial step is to gather additional information about the lesion’s history and changes over time before initiating a referral. Immediate consultation is not indicated without assessing for changes.

B. Nothing, this is a normal skin change in the older client: Although some skin changes, like age spots or benign nevi, are common in older adults, a new, dark, or changing mole requires evaluation. Assuming it is normal may delay detection of potentially malignant lesions, such as melanoma.

C. Ask the client if the mole always looked this way: Determining whether the mole is new or has changed in size, shape, color, or texture helps identify lesions that may need further evaluation. This assessment is critical because changes over time are key warning signs of malignancy according to the ABCDE criteria.

D. Document the presence and appearance of the mole: Documentation is essential for baseline records, but it does not provide the PN with information about whether the lesion is new or changing. Accurate history from the client is required before determining if further action is necessary.

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Correct Answer is D

Explanation

Rationale:

A. Palpation: Palpation is primarily used to assess tactile sensations such as tenderness, masses, or vibrations (tactile fremitus). It does not provide an accurate measure of chest dimensions or the anterior-posterior diameter.

B. Percussion: Percussion is used to evaluate underlying structures, detect fluid, air, or masses, and assess organ borders. While it provides information about density, it does not allow measurement of the chest’s anterior-posterior diameter.

C. Auscultation: Auscultation is used to assess lung and airway sounds, such as breath sounds or adventitious sounds. It provides no visual or dimensional data about chest shape or diameter.

D. Observation: Observation is the correct technique for assessing the anterior-posterior chest diameter. The nurse visually inspects the chest from the side to compare the front-to-back measurement with the transverse diameter. This helps identify abnormalities such as barrel chest, which can be indicative of COPD or other pulmonary conditions.

A. Position the client on the left side and reassess. B. Document the lack of an apical pulse in the medical record. C. Assess the client for signs of diminished cardiac output. D. Count the pulse rate and volume at the radial site.

Correct Answer is A

Explanation

Rationale:

A. Position the client on the left side and reassess: Placing the client in the left lateral decubitus position shifts the heart closer to the chest wall, making the PMI easier to palpate, especially in older adults or clients with a thick chest wall. This maneuver is a standard initial approach to improve assessment accuracy before concluding that the apical site is non-palpable.

B. Document the lack of an apical pulse in the medical record: Recording a missing apical impulse without further assessment is premature. The inability to palpate the PMI in the supine position can be influenced by positioning or body habitus, additional assessment techniques should be attempted first.

C. Assess the client for signs of diminished cardiac output: While important for overall cardiac assessment, evaluating for symptoms such as hypotension, fatigue, or altered mentation does not address the immediate issue of locating the PMI. This action is supportive but not the priority initial step.

D. Count the pulse rate and volume at the radial site: Measuring the radial pulse provides information on peripheral perfusion but does not substitute for assessing the apical impulse, which is critical for detecting dysrhythmias or confirming heart rate and rhythm, particularly in a bedfast client.

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When caring for an older adult client, the practical nurse (PN) notices a small, black mole on the posterior aspect of the client's calf. Which action should the PN take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When assessing a client's respiratory status, which technique should the practical nurse use to assess the anterior-posterior (AP) chest diameter?

Correct Answer is D

Explanation

The practical nurse (PN) wants to assess heart sounds at the apical site of a bedfast client who is lying in a supine position. The PN is unable to palpate the PMI (point of maximal impulse). Which is the best initial nursing action?

Correct Answer is A

Explanation

When caring for an older adult client, the practical nurse (PN) notices a small, black mole on the posterior aspect of the client's calf. Which action should the PN take?

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