A client asks the nurse to look at a mole located on the back. The client tells the nurse that the mole has changed from brown to black and enlarged in size. Which is the priority nursing action?

Advise the client to see his healthcare provider for immediate evaluation.

Encourage the client to keep checking the mole with a magnifying mirror.

Ask the client if he often spends time outside in the sun without a shirt.

Offer to teach a family member how to monitor the skin around the mole.

Answer and Explanation

The Correct Answer is A

A. Changes in a mole's color, size, or shape could indicate melanoma, a serious type of skin cancer. Immediate evaluation by a healthcare provider is critical for early diagnosis and treatment.
B. While monitoring the mole is important, immediate professional evaluation is the priority to rule out malignancy.
C. Assessing sun exposure is relevant for skin cancer risk, but it is not the immediate priority in this scenario.
D. Teaching a family member to monitor the mole is not sufficient when there is a significant change that requires professional evaluation.

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Correct Answer is D

Explanation

A. Withdrawing and reinserting the NGT should only be done if the tube is misplaced or dislodged.
B. Sending the fluid to the lab is unnecessary unless there is a specific concern, such as infection.
C. Connecting the NGT to wall suction should only be done after confirming proper placement.
D. Determining the pH value of the aspirated fluid helps verify that the NGT is correctly positioned in the stomach. Gastric fluid typically has a pH of 1 to 5, confirming proper placement.

A. Maintain a cheerful and calm appearance while spending time with the client. B. Listen for changes in what the client hopes for and try to help meet the goals. C. Avoid the client having to make any decisions to help save the client's energy. D. Offer meals prepared with the client's favorite foods at frequent, regular intervals.

Correct Answer is B

Explanation

A. A cheerful and calm appearance may not always align with the client's emotional needs and could feel insincere.
B. As the client nears the end of life, their hopes may shift, and it is crucial for the spouse to listen and help fulfill these evolving goals to provide comfort and maintain dignity.
C. Encouraging the client to make decisions as they are able can empower them, rather than avoiding decision-making.
D. Offering favorite foods is thoughtful but does not directly address the emotional and psychological aspects of hopelessness.

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A client asks the nurse to look at a mole located on the back. The client tells the nurse that the mole has changed from brown to black and enlarged in size. Which is the priority nursing action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While assessing placement of a nasogastric tube (NGT), the nurse aspirates cloudy green fluid into a syringe. Which intervention should the nurse implement?

Correct Answer is D

Explanation

The home care nurse has identified the nursing problem, "risk for hopelessness" for a client who is terminally ill with a life expectancy of several days. Which instruction should the nurse provide to the client's spouse?

Correct Answer is B

Explanation

Which client is at greatest risk for aspiration?

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