A nurse is collecting data from a client who reports finding a new skin lesion. Which of the following actions is the nurse's priority?

Document the client's history of skin allergies.

Photograph the lesion for the client's medical record.

Identify when the client first noticed the lesion.

Instruct the client on the use of daily sunscreen products.

Answer and Explanation

The Correct Answer is C

A.   Document the client's history of skin allergies: While important for the client's overall care, documenting the history of skin allergies is not the priority when assessing a new skin lesion.
B.   Photograph the lesion for the client's medical record: Documenting the appearance of the lesion is important for the client's medical record, but it is not the priority when initially assessing the lesion.
C.   Identify when the client first noticed the lesion: The priority is to gather information about the onset and characteristics of the lesion to determine its potential severity and urgency of intervention.
D.   Instruct the client on the use of daily sunscreen products: While sun protection is important for skin health, it is not the priority when assessing a new skin lesion.

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Correct Answer is A

Explanation

A. "All patients are presumed infectious.": This statement reflects the principle of universal precautions, which assumes that all patients may potentially transmit infectious agents, regardless of their diagnosis or symptoms. It emphasizes the importance of implementing infection prevention practices for every patient encounter to minimize the risk of transmission.
B. "Isolation is not required for most diseases.": While isolation precautions may not be required for all diseases, the statement does not fully capture the concept of universal precautions.
C. "Patients with a known infection are placed in isolation only when they are admitted.": This statement is not accurate as patients with known infections should be placed in isolation as soon as possible to prevent the spread of infection to others.
D. "Patients are not considered infectious until confirmed so by the laboratory.": Waiting for laboratory confirmation before implementing infection control measures could lead to delays in preventing transmission, as patients may be infectious before laboratory results are available.

A. To relieve itching or discomfort B. To improve the appearance of the skin C. To remove a suspicious lesion D. To treat a skin infection

Correct Answer is C

Explanation

A. To relieve itching or discomfort: Skin biopsies are not typically performed to relieve itching or discomfort. Other treatments, such as topical medications or systemic therapies, may be used for symptomatic relief.
B. To improve the appearance of the skin: Skin biopsies are not performed for cosmetic purposes. They are diagnostic procedures used to obtain tissue samples for examination under a microscope to diagnose or rule out various skin conditions.
C. To remove a suspicious lesion: Skin biopsies are commonly performed to remove suspicious lesions, such as moles, growths, or areas of abnormal skin, for further evaluation and diagnosis.
This helps determine if the lesion is benign or malignant and guides subsequent treatment decisions.
D. To treat a skin infection: Skin biopsies are not performed as a primary treatment for skin infections. Biopsies are diagnostic procedures used to obtain tissue samples for analysis and are not typically indicated for treating infections.

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A nurse is collecting data from a client who reports finding a new skin lesion. Which of the following actions is the nurse's priority?

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