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 B

Explanation

A. Normal white blood cell count: In wound sepsis, the white blood cell count is typically elevated as part of the body's immune response to infection, not normal.
B. Fever and chills: Fever (hyperthermia) and chills are common signs of systemic infection, including wound sepsis. They indicate an inflammatory response and activation of the body's defense mechanisms.
C. Decreased pain at the wound site: Increased pain at the wound site is more commonly associated with wound infection, not decreased pain.
D. Redness and swelling: Redness (erythema) and swelling (edema) are local signs of inflammation and can be present in infected wounds, but they are not specific to wound sepsis and may occur in non-infected wounds as well.

A. Administering analgesic medications B. Performing gentle massage on the affected area C. Applying a heating pad to the affected area D. Using topical antibiotics on the affected area

Correct Answer is A

Explanation

A. Administering analgesic medications: Analgesic medications, such as nonsteroidal anti-inflammatory drugs (NSAIDs) or opioids, can help alleviate pain associated with impaired skin integrity by reducing inflammation and blocking pain signals.
B. Performing gentle massage on the affected area: While massage can sometimes provide relief for certain types of pain, it may not be appropriate for all types of impaired skin integrity and could potentially exacerbate the condition or cause further damage.
C. Applying a heating pad to the affected area: Heat therapy may be contraindicated for certain types of impaired skin integrity, as it can increase inflammation and worsen pain. It is not
typically recommended as a primary intervention for managing pain in this context.
D. Using topical antibiotics on the affected area: Topical antibiotics are used to treat or prevent infections but are not primarily indicated for pain management associated with impaired skin
integrity.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following is a common sign of wound sepsis?

Correct Answer is B

Explanation

Which of the following interventions can help manage pain associated with impaired skin integrity?

Correct Answer is A

Explanation

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