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

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A reason:

Sodium 140 mEq/L is incorrect because it falls within the normal range (135-145 mEq/L).

Choice B reason:

A potassium level of 5.8 mEq/L is appropriate because it is above the normal range (typically around 3.5-5.0 mEq/L). Elevated potassium levels, known as hyperkalaemia, can lead to serious cardiac disturbances, including arrhythmias or even cardiac arrest. It is important to notify the healthcare provider promptly so that appropriate interventions can be initiated to address the high potassium level.

Choice C reason:

Calcium 9.6 mg/dL is incorrect because it is within the normal range (8.5-10.5 mg/dL).

Choice D reason:

Magnesium 1.9 mEq/L is incorrect because it is within the normal range (1.5-2.5 mEq/L).

A. Develop a plan for the client to integrate the change into her lifestyle. B. Assist the client in setting goals to make the change. C. Recommend small changes for the client to make to change her behavior over time. D. Present information about the benefits of quitting smoking.

Correct Answer is D

Explanation

A. Develop a plan for the client to integrate the change into her lifestyle: Developing a plan for integrating change into one's lifestyle is more appropriate during the preparation stage when the client is actively planning to make a change. During the contemplation stage, the focus is on considering change rather than developing a detailed plan.
B. Assist the client in setting goals to make the change: Setting specific goals is more appropriate during the preparation stage when the client is actively planning to make a change. During the contemplation stage, the client is not yet ready to commit to specific goals.
C. Recommend small changes for the client to make to change her behavior over time: During the contemplation stage of health behavior change, clients are considering making a change but are not yet committed to taking immediate action. This is also more suitable for the preparation or action stages.
D. In the contemplation stage, the client is aware of the problem and is considering making a change but has not yet committed to action. Providing information about the benefits can help the client move toward the next stage of change.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

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