Nokea
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.
You may also like to solve these questions
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.
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 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.
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 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.