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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.
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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 and identifies that the client has pallor conjunctivae. Which focused assessment should the nurse complete next?
- A. Nail bed inspection
- B. Hemoglobin and hematocrit
- C. Skin turgor assessment
- D. Capillary refill time
Correct Answer: B
Rationale: Pallor conjunctivae may indicate anemia, so the nurse should assess hemoglobin and hematocrit levels next to evaluate for possible anemia.
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).
A nurse assesses a client who has multiple areas of ecchymosis on both arms. Which question should the nurse ask first?
- A. Are you using lotion on your skin?
- B. Do you have a family history of this?
- C. Do your arms itch?
- D. What medications are you taking?
Correct Answer: D
Rationale: Certain drugs such as aspirin, warfarin, and corticosteroids can lead to easy or excessive bruising, which can result in ecchymosis. The other options would not provide information about bruising.
After teaching a client who expressed concern about a rash located beneath her breast, a nurse assesses the clients understanding. Which statement indicates the client has a good understanding of this condition?
- A. This rash is probably due to fluid overload.
- B. I need to wash this area daily with antibacterial soap.
- C. I can use powder to keep this area dry.
- D. I will schedule a mammogram as soon as I can.
Correct Answer: C
Rationale: Rashes limited to skinfold areas (e.g., on the axillae, beneath the breasts, in the groin) may reflect problems related to excessive moisture. Using powder to keep the area dry is an appropriate measure to manage this condition.