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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.
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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.
A nurse assesses an older adult client with a skin disorder shown in the image. How should the nurse document this finding?
- A. Petechiae
- B. Ecchymoses
- C. Actinic lentigo
- D. Senile angiomas
Correct Answer: A
Rationale: Petechiae are small, reddish-purple, non-raised lesions that do not fade or blanch with pressure. Ecchymoses are larger areas of hemorrhaging (bruising), actinic lentigo presents as paper-thin, transparent skin, and senile angiomas are red, raised lesions.
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 teaches a client to perform total skin self-examination on a monthly basis. Which statements should the nurse include for this client's teaching? (Select all that apply.)
- A. Look for asymmetry of shape and irregular borders.
- B. Assess for color variation within each lesion.
- C. Monitor for symmetry and regular borders.
- D. Monitor for edema or swelling of tissues.
- E. Focus your assessment on skin areas that itch.
Correct Answer: A,B
Rationale: Clients should be taught to examine each lesion following the ABCDE features associated with skin cancer: asymmetry of shape and irregular borders, color variation within one lesion, diameter greater than 6 mm, and evolving or changing in any feature.
While assessing a client, a nurse detects a bluish tinge to the clients palms, soles, and mucous membranes. Which action should the nurse take next?
- A. Ask the client about current medications he or she is taking.
- B. Use pulse oximetry to assess the clients oxygen saturation.
- C. Assess the clients lung fields for adventitious sounds.
- D. Palpate the clients bilateral radial and pedal pulses.
Correct Answer: B
Rationale: Cyanosis can be present when impaired gas exchange occurs. In a client with dark skin, cyanosis can be seen because the palms, soles, and mucous membranes have a bluish tinge. The nurse should assess for systemic oxygenation before continuing with other assessments.