A nurse is observing a newly licensed nurse perform focused data collection on a client who has developed a skin condition. Which of the following questions by the newly licensed nurse requires intervention by the nurse?

"How do you handle stress?"

"Does your skin condition keep you awake at night?"

"How does your skin condition make you feel about yourself?"

"Have you had any changes in your diet?"

Answer and Explanation

The Correct Answer is A

A. "How do you handle stress?" While stress may influence some skin conditions (e.g., psoriasis, eczema), this question is not directly related to a focused skin assessment and may be too vague or irrelevant.

B. "Does your skin condition keep you awake at night?" Skin conditions such as eczema or urticaria can cause pruritus, leading to sleep disturbances. This is a relevant question.

C. "How does your skin condition make you feel about yourself?" Skin conditions can affect body image and self-esteem, making this an important question for psychosocial assessment.

D. "Have you had any changes in your diet?" Certain food allergies or deficiencies can trigger dermatologic conditions (e.g., celiac disease, atopic dermatitis), making this question appropriate.

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Correct Answer is A

Explanation

helps train the body to respond to natural urges.

B. Immediately before meals. Although eating stimulates peristalsis, this is not the most effective approach because the client may not be ready to defecate at that time.

C. Every 2 hr day and night. A rigid 2-hour schedule is unnecessary and may cause distress or inconvenience for the client.

D. After every drink or meal. While eating may trigger the gastrocolic reflex, forcing bathroom visits after every meal or drink is not always appropriate.

A. Assess respiratory rate and rhythm B. Pulse oximetry reading C. Assess bowel sounds D. Auscultate lung sounds E. Determine two touch discrimination in the lower extremities

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

Explanation

A. Assess respiratory rate and rhythm. Changes in breathing pattern may indicate hypoxia, respiratory distress, or metabolic acidosis.

B. Pulse oximetry reading. Measures oxygen saturation, which is critical in assessing oxygenation and ventilation status.

C. Assess bowel sounds. While anxiety and stress can affect the gastrointestinal system, bowel sounds are not directly relevant in this situation.

D. Auscultate lung sounds. Important for identifying wheezing, crackles, or diminished breath sounds, which may indicate bronchospasm, fluid overload, or airway obstruction.

E. Determine two-point discrimination in the lower extremities. This test assesses neurological function, which is not a priority in a client presenting with respiratory distress and anxiety.

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A nurse is observing a newly licensed nurse perform focused data collection on a client who has developed a skin condition. Which of the following questions by the newly licensed nurse requires intervention by the nurse?

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A nurse is observing a newly licensed nurse perform focused data collection on a client who has developed a skin condition. Which of the following questions by the newly licensed nurse requires intervention by the nurse?