Nokea
A nurse assesses a client who has two skin lesions on his chest. Each lesion is the size of a dime and has irregular borders. How should the nurse document this finding?
- A. Annular
- B. Diffuse
- C. Clustered
- D. Linear
Correct Answer: B
Rationale: Diffuse is used to describe lesions that are widespread. The description of two lesions with irregular borders does not fit annular (circular), clustered (grouped together), or linear (in a straight line).
You may also like to solve these questions
A nurse assesses a client who is admitted with inflamed soft-tissue folds around the nail plates. Which question should the nurse ask to elicit information about this possible condition?
- A. What do you do for a living?
- B. Are your nails professionally manicured?
- C. Do you have diabetes mellitus?
- D. Do you have a fungal infection?
Correct Answer: A
Rationale: The condition chronic paronychia is common in people with frequent intermittent exposure to water, such as homemakers, bartenders, and laundry workers. The other questions would not provide information specifically related to the assessment finding.
A nurse plans care for a client who has a wound that is not healing. Which focused assessments should the nurse complete to develop the client's plan of care? (Select all that apply.)
- A. Height
- B. Allergies
- C. Alcohol use
- D. Prealbumin laboratory results
- E. Liver enzyme laboratory results
Correct Answer: A,C,D
Rationale: Nutritional status can have a significant impact on skin health and wound healing. The care plan for a client with poor nutritional status should include a high-protein, high-calorie diet. Assessing height, alcohol use, and prealbumin laboratory results will provide information related to vitamin and protein deficiencies and obesity. Allergies and liver enzyme results will not provide information about nutritional status or wound healing.
A nurse assesses a client who has open lesions. Which action should the nurse take first?
- A. Put on gloves.
- B. Ask the client about his or her occupation.
- C. Assess the clients pain.
- D. Obtain vital signs.
Correct Answer: A
Rationale: Nurses should wear gloves as part of Standard Precautions when examining skin that is not intact. The other options should be completed after gloves are put on.
A nurse assesses an older adult's skin. Which findings require immediate referral? (Select all that apply.)
- A. Excessive moisture under skin folds
- B. Increased hair thinning
- C. Increased presence of fungal toenails
- D. Lesion with various colors
- E. Spider veins on legs
- F. Asymmetric 6-mm dark lesion on forehead
Correct Answer: D,F
Rationale: Skin lesions with various colors and an asymmetric 6-mm dark lesion fit two of the American Cancer Society's hallmark signs for cancer according to the ABCD method. Other manifestations are variants of normal seen in various age groups.
A nurse assesses a client who has a chronic skin disorder. Which finding indicates the client is effectively coping with the disorder?
- A. Clean hair, skin, and nails
- B. Poor eye contact
- C. Disheveled appearance
- D. Drapes a scarf over the face
Correct Answer: A
Rationale: The nurse should complete a psychosocial assessment to determine if the client is coping effectively. Signs of adequate coping include clean hair, skin, and nails, good eye contact, and being socially active. A disheveled appearance and draping a scarf over the face to hide the client's appearance demonstrate that the client may not be coping effectively.