A nurse is caring for a client with a new skin inflammation on the chest. Which of the following is an important assessment question to ask the client?
How many people live in your home?
Did you have a recent exposure to Irritants?
Is nausea associated with your rash7
What is your body mass index?
The Correct Answer is B
-
A. How many people live in your home?
This question pertains to social and environmental factors but is not directly related to assessing skin inflammation on the chest. While social factors can impact overall health, such as stress levels or exposure to infectious agents, the number of people living in the client's home is unlikely to be directly related to a new skin inflammation unless there are specific circumstances, such as sharing personal care products or close contact with others who have similar skin issues.
B. Did you have a recent exposure to irritants?
This question is highly relevant to assessing a new skin inflammation on the chest. Exposure to irritants or allergens can trigger or worsen skin conditions, such as contact dermatitis or allergic reactions. By asking about recent exposure to potential irritants like new detergents, soaps, fabrics, chemicals, or environmental factors, the nurse can gather important information to identify possible triggers for the skin inflammation.
C. Is nausea associated with your rash?
Nausea is typically not directly associated with a skin rash or inflammation unless there is a systemic condition or allergic reaction causing both symptoms. While it's important to assess for any systemic signs or symptoms that may be related to the skin condition, such as fever or malaise, specifically asking about nausea may not provide relevant information about the skin inflammation on the chest.
D. What is your body mass index?
Body mass index (BMI) is a measure of body weight relative to height and is not directly related to assessing a new skin inflammation on the chest. While obesity or changes in body weight can sometimes contribute to skin issues, such as friction-related dermatitis or hormonal changes affecting skin health, BMI alone is not a primary assessment parameter for localized skin conditions unless there are specific concerns related to weight-related skin problems.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Inform the client that the recovery nurse will instruct them how to manage postoperative pain:
This is an important aspect of postoperative care, but it is typically addressed by the post-anesthesia care unit (PACU) or recovery nurse after surgery rather than in the preoperative education phase. While pain management education is crucial, the focus of preoperative education is usually on what to expect before, during, and immediately after surgery.
B. Remind the client they will return to their room after surgery:
This information is part of the preoperative instructions and helps alleviate anxiety by providing clarity about the post-surgical process. However, it may not be the most critical aspect of preoperative education compared to other options.
C. Provide instructions about how to cough and deep breathe effectively:
This is a key nursing intervention to include in preoperative education. Teaching the client how to cough and deep breathe effectively helps prevent postoperative complications such as atelectasis and pneumonia. These breathing techniques are typically taught preoperatively to ensure the client understands and can perform them correctly after surgery.
D. Notify the client that they will receive a food tray in the recovery room:
While it's important for the client to understand the postoperative diet plan, including any dietary restrictions or instructions, this information is usually provided after surgery rather than in the preoperative education phase.
Correct Answer is A
Explanation
A. Colonization - replicating microorganisms: not yet Infected
This pairing is correct. Colonization refers to the presence and replication of microorganisms on the wound surface. At this stage, the wound is not yet infected, as there may be microorganisms present, but they have not caused an inflammatory response or tissue damage.
B. Systemic infection - Wound is darker than the surrounding skin with noted drainage present
This description does not match the stage of systemic infection. Systemic infection refers to an infection that has spread beyond the initial wound site, affecting the entire body systemically. The symptoms of systemic infection may include fever, increased heart rate, malaise, and altered mental status. The description provided seems more indicative of a local infection with drainage.
C. Contaminated - infection beyond the wound
This pairing is incorrect. Contaminated wounds refer to wounds with a high risk of infection due to the presence of foreign material or significant contamination. However, contamination does not necessarily mean that an infection has already developed beyond the wound. It signifies a risk of infection but does not define the infection stage itself.
D. Local infection - sepsis
This pairing is incorrect. A local infection is confined to the wound site and may present with symptoms such as erythema, warmth, swelling, pain, and purulent drainage. Sepsis, on the other hand, is a severe systemic response to infection, characterized by widespread inflammation and organ dysfunction. Sepsis is not synonymous with a local infection; it represents a more advanced and life-threatening stage of infection.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.