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","D","E"]

Explanation

A. Hypoglycemic: Hypoglycemia is not typically considered a sign or symptom of sepsis. In sepsis, blood glucose levels may fluctuate, but hypoglycemia is less common.
B. Elevated White Blood Count: An elevated white blood count (leukocytosis) is a common sign of sepsis, indicating the body's immune response to infection.
C. Pruritus: Pruritus, or itching, is not typically associated with sepsis. Itching may occur in certain skin conditions or allergic reactions but is not a hallmark sign of sepsis.
D. Hypotension: Hypotension, or low blood pressure, is a serious sign of sepsis and can indicate septic shock, a life-threatening complication.
E. Altered Mental Status: Altered mental status, such as confusion, disorientation, or decreased level of consciousness, can occur in sepsis due to systemic inflammation and impaired perfusion to the brain.

A. Pupil size and reaction B. Heart rate and blood pressure C. Respiratory rate and oxygen saturation D. Skin turgor and moisture

Correct Answer is D

Explanation

A. Pupil size and reaction: Pupil size and reaction are typically assessed to monitor neurological function and are not directly related to tissue integrity.
B. Heart rate and blood pressure: Heart rate and blood pressure are vital signs that provide information about cardiovascular function but do not specifically assess tissue integrity.
C. Respiratory rate and oxygen saturation: Respiratory rate and oxygen saturation are indicators of respiratory function and oxygenation status and are not directly related to tissue integrity.
D. Skin turgor and moisture: Skin turgor, the skin's ability to return to its normal shape after being pinched, and moisture levels are important assessments for monitoring tissue hydration and integrity. Changes in skin turgor and moisture can indicate dehydration, which can impair tissue integrity and wound healing.

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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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Naxlex Comprehensive Predictor Exams

A nurse is collecting data on a client who has an infection. Which of the following findings are signs and symptoms of sepsis? (Select All that Apply.)

Correct Answer is ["B","D","E"]

Explanation

Which of the following assessments should be performed to monitor for impaired tissue integrity?

Correct Answer is D

Explanation

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