A nurse is assessing the skin of a client who has worked outdoors for the past 20 years. Which of the following findings is the nurse's priority?
Skin tags noted in the neck region
A change in appearance of a mole on the shoulder
Atrophic wart on the left index finger
A flat, nonpalpable, discolored area of skin on the trunk
The Correct Answer is B
Choice A reason:
Skin tags noted in the neck region: Skin tags are generally benign and not typically a cause for immediate concern. While they can be removed if desired, they are not as urgent as assessing potential changes in moles for skin cancer.
Choice B reason:
A change in appearance of a mole on the shoulder is the appropriate answer. The nurse's priority should be a change in the appearance of a mole on the shoulder. Changes in the colour, size, shape, or texture of a mole can indicate potential skin cancer, especially malignant melanoma. Timely assessment and appropriate follow-up are crucial to catch any skin cancer early and ensure effective treatment.
Choice C reason:
The atrophic wart on the left index finger is incorrect. An atrophic wart is a benign skin condition and is not typically associated with skin cancer or immediate danger. It may not require urgent assessment.
Choice D reason:
A flat, nonpalpable, discoloured area of skin on the trunk: While any change in skin appearance should be assessed, a nonpalpable, discoloured area may not present an immediate concern unless it shows signs of growth, change, or other concerning features.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
False imprisonment is the correct answer because it occurs when a person intentionally restricts the freedom of movement of another person without proper consent or legal justification. In this scenario, the AP is threatening to place the client in restraints against their will if they do not comply with bed rest. This action is a violation of the client's rights and constitutes false imprisonment.
Choice B reason:
Defamation of character is incorrect: Defamation involves making false statements about someone that harm their reputation. It doesn't apply to this scenario.
Choice C reason:
Battery is incorrect: Battery involves intentional harmful or offensive physical contact with another person without their consent. There is no indication of physical contact in this situation.
Choice D reason:
Assault is incorrect. Assault refers to the intentional threat or act that causes fear of imminent harmful or offensive contact. While there is a threat implied in this scenario, the threat is of false imprisonment rather than physical harm, making false imprisonment a more accurate description of the tort.
Correct Answer is B
Explanation
Choice A reason:
Performing percussion over the lower back: While percussion is part of the postural drainage technique, the specific areas to be percussed depend on the client's individualized care plan, which is based on the location of lung segments affected by cystic fibrosis. The nurse should follow the care plan and target the appropriate lung segments for percussion.
Choice B reason:
Covering the area of percussion with a towel is correct. When performing postural drainage with percussion and vibration for a client with cystic fibrosis, it is important to cover the area of percussion with a towel. This helps protect the client's skin and prevent discomfort or injury during the procedure. The towel acts as a barrier between the nurse's hand and the client's skin, allowing for effective percussion while minimizing friction and pressure
Choice Creason:
Scheduling postural drainage after meals: Postural drainage is ideally performed before meals or at least 1-2 hours after meals to avoid potential discomfort or vomiting due to the positioning and movement during the procedure.
Choice Dreason:
Instructing the client to exhale quickly during vibration: Vibration is typically performed during the client's exhalation phase, but the instruction should focus on slow, controlled exhalation rather than quick exhalation.
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