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 B

Explanation

A. "I cough a lot at night and it keeps me up half the night." Night-time coughing can be associated with various conditions, including asthma, GERD, or postnasal drip, but it is not specifically indicative of orthopnoea.

B. "I sleep on three pillows at night." This supports orthopnoea, which is difficulty breathing when lying flat. Clients with orthopnoea often use multiple pillows to elevate their upper body to alleviate shortness of breath.

C. "I have multiple attacks of wheezing almost daily." Frequent wheezing is more indicative of asthma or other obstructive airway diseases, not orthopnoea.

D. "It doesn't take much activity before I'm out of breath." This describes dyspnoea on exertion, which is different from orthopnoea, as it refers to difficulty breathing during physical activity rather than when lying down.

A. Explain to the child the reasons an examination is needed. B. Talk to the parent and gradually focus on the child's toy. C. Complete the assessment while allowing the child to cry. D. Request extra staff to help with the nursing assessments.

Correct Answer is B

Explanation

A. Explaining the exam: Preschool-aged children might not fully understand the need for an exam, and this might not alleviate their anxiety.

B. Talking to parent and focusing on toy: This strategy prioritizes calming the child first. Talking to the parent helps gather information while the nurse gradually gains the child's trust by acknowledging their toy. This can create a more positive and collaborative environment.

C. Completing assessment while crying: This can be stressful for the child and might hinder an accurate assessment.

D. Requesting extra staff: While additional support might be helpful, the initial approach should focus on building rapport with the child.

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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

Which subjective assessment data supports the nurse's conclusion that a client is experiencing orthopnea?

Correct Answer is B

Explanation

A parent brings a preschool aged client to the clinic because of having diarrhea, vomiting, and high fevers for the past three days. The child begins to cry and cling to the parent when the nurse enters the examination room. Which action should the nurse implement to get the child to cooperate?

Correct Answer is B

Explanation

A client is complaining of severe pain after being medicated one hour ago with hydrocodone with acetaminophen one tablet orally. Which intervention should the nurse implement next?

While assessing the legs of an adult client, the nurse observes leathery-looking skin. The client reports aching, tired legs that swell if standing for long periods of time. To screen for venous insufficiency, the nurse should ask the client if they have experienced which subjective finding?

Which assessment finding of an older adult client should the nurse associate with normal aging?

The nurse prepares to begin a systematic assessment of a client's heart sounds. Upon positioning the stethoscope as seen in the picture, which should the nurse do first?

In assessing an older adult client, the nurse notes that the client's right arm muscles feel soft and boggy. To gather additional data related to this finding, which assessment should the nurse complete next?

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

In auscultating for the presence of a carotid artery bruit, the nurse places the bell of the stethoscope at which location?

An adolescent's mother calls the primary healthcare provider's office to Inquire about the results of her daughter's serum test results that were drawn last week. Since it is the teenager's 18th birthday, how should the nurse respond to this mother's inquiry?