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