Which finding, obtained during a skin assessment of a student, should the school nurse report to the healthcare provider?

Multiple maculopapular pustules over forehead and chin on an adolescent student.

Red, swollen, painful nodule located on the upper back of a school aged student.

Small, white flecks on the hair shafts throughout scalp on a school aged child.

Bilateral patellar abrasions with eschar formation on a preschool aged student.

Answer and Explanation

The Correct Answer is B

A. Multiple maculopapular pustules over forehead and chin on an adolescent student: These pustules could be indicative of an infectious process, such as acne or impetigo. While not necessarily an emergency, it’s important to assess and potentially treat these skin lesions promptly. The school nurse should report this to the healthcare provider for further evaluation.

B. Red, swollen, painful nodule located on the upper back of a school-aged student: This finding raises concern for an abscess or localized infection. The pain, redness, and swelling suggest an inflammatory process. The nurse should promptly report this to the healthcare provider for assessment and appropriate management.

C. Small, white flecks on the hair shafts throughout the scalp on a school-aged child: These white flecks are likely nits (lice eggs). While not an emergency, they do require attention. The nurse should inform the parents or guardians and recommend appropriate treatment. However, this finding does not necessitate immediate reporting to the healthcare provider.

D. Bilateral patellar abrasions with eschar formation on a preschool-aged student: Abrasions with eschar (dead tissue) formation can indicate a deeper injury. The nurse should report this to the healthcare provider promptly for assessment and wound care recommendations.

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Correct Answer is C

Explanation

A. Multiple yellow lesions with a grainy surface. These could indicate xanthomas, which are associated with lipid disorders and may warrant further investigation and treatment.

B. Large, flat, dark red irregular area on the neck. This could be a port-wine stain, which is typically a congenital condition and may not require immediate medical intervention unless associated with other symptoms.

C. Bluish discoloration of the nail beds. This indicates cyanosis, which can be a sign of hypoxia or cardiovascular issues. It requires prompt evaluation by a healthcare provider to determine the underlying cause and necessary interventions.

D. Multiple silver striae on the abdomen. Striae, or stretch marks, are usually benign and often result from rapid weight changes or hormonal variations. They typically do not require immediate medical attention.

A. Request social services to make a home visit. B. Interview the client privately without the adult child present. C. Complete a neurological and musculoskeletal assessment. D. Ask the client if an assisted living facility is an option for safety concerns.

Correct Answer is B

Explanation

A. Request social services to make a home visit. This is important but not the immediate priority. It can be part of the long-term intervention plan once the immediate safety and health of the client are ensured.

B. Interview the client privately without the adult child present. This is the highest priority. It allows the nurse to assess for potential abuse or neglect without the influence or intimidation of the accompanying adult, ensuring the client can speak freely.

C. Complete a neurological and musculoskeletal assessment. This is important to assess the extent of the injuries and the client's overall physical health, but it follows the immediate need to ensure the client's safety and ability to speak freely about their situation.

D. Ask the client if an assisted living facility is an option for safety concerns. While exploring living arrangements is important for long-term safety, it is not the highest priority. Ensuring the client's immediate safety and obtaining accurate information about their situation takes precedence.

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Which finding, obtained during a skin assessment of a student, should the school nurse report to the healthcare provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Correct Answer is C

Explanation

Correct Answer is B

Explanation

The nurse is assessing a darkly pigmented child for cyanosis. Which finding indicates cyanosis?

Which assessment finding supports the client statement, "My feet swell all the time?"

The charge nurse observes a practical nurse (PN) measuring the waist circumference of a client who has expressed a concern about health problems related to obesity. Which action should the nurse implement?

When-obtaining an adolescent's health history, which intervention is most important of the nurse to implement?

When performing a neurologic assessment on an alert client, the nurse observes that the client's pupils are both round, 3 mm in size, and respond briskly to light. Which notation should the nurse use when documenting the assessment?

The nurse is assessing the lung sounds of a preschooler. Which action should the nurse implement to ensure the child's cooperation?

When performing a physical assessment, palpation reveals to the clinic nurse that a client has an enlarged thyroid gland. What action should the nurse take in response to this finding?

In assessing a male client's level of consciousness, the nurse determines that the client does not open his eyes spontaneously. Which should the nurse do next?