A nurse is observing a newly licensed nurse who is performing a focused skin assessment on a client who reports a skin condition. Which of the following questions by the newly licensed nurse requires intervention?
Have you had any changes in your diet?
How do you handle stress?
How does your skin condition make you feel?
Does your skin condition keep you awake at night?
None
None
The Correct Answer is B
Choice A reason:
Asking about dietary changes is relevant to a skin assessment, as diet can influence skin health. However, this question does not require intervention unless the dietary changes are directly related to the skin condition. If the client has been advised to follow a specific diet for their skin condition, then the nurse should ensure compliance with that diet.
Choice B reason:
This question shifts the focus from the skin condition’s characteristics and impact to general coping mechanisms. It does not help determine the lesion’s symptoms, triggers, or functional effects, and thus does not align with a targeted skin assessment framework, requiring intervention.
Choice C reason:
Exploring how the skin issue affects the client’s feelings reveals psychosocial stressors and the emotional burden of living with a visible condition. This insight supports holistic care planning, adherence strategies, and therapeutic rapport.
Choice D reason:
Sleep disturbances can be a consequence of skin conditions, especially if they involve itching or pain. This question is pertinent to the assessment and does not require intervention. The information gathered can help in formulating a comprehensive care plan that addresses the client's comfort and sleep quality.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
Choice A reason:
Raisins are dried grapes and are known to have a higher concentration of nutrients, including potassium. For individuals with chronic kidney disease (CKD), consuming foods like raisins that are high in potassium can lead to hyperkalemia, a condition where potassium levels in the blood are higher than normal. This can be dangerous as it may cause heart rhythm problems.
Choice B reason:
Asparagus is considered a lower-potassium food, making it a safer choice for people with CKD. It's important for individuals with CKD to manage their potassium intake, but asparagus can be included in their diet in appropriate portions.
Choice C reason:
Bananas are well-known for being rich in potassium. For someone with CKD, eating bananas can contribute to an excessive intake of potassium, which their kidneys may not be able to eliminate efficiently, potentially leading to hyperkalemia.
Choice D reason:
Tomatoes, including tomato products like sauces, juices, and purees, are high in potassium. Therefore, they should be limited or avoided in the diet of a person with CKD to prevent complications associated with high potassium levels.
Choice E reason:
Green beans are considered to be a lower-potassium vegetable. They can be included in a kidney-friendly diet, provided they are consumed in moderation and balanced with other dietary needs.
Correct Answer is B
Explanation
Choice A reason:
Restricting the client's oral fluid intake is not typically recommended as part of postoperative care following TURP. In fact, maintaining adequate hydration is important to help flush the bladder and prevent clot formation.
Choice B reason:
It is common for clients to feel a constant urge to void due to the irritation of the bladder from the catheter and the continuous bladder irrigation. Reminding the client that this sensation is normal and expected can help alleviate anxiety and provide reassurance.
Choice C reason:
Monitoring the client's urine output is important to ensure that the bladder irrigation is effective and that there are no signs of obstruction. However, it should be done more frequently than every 6 hours, especially in the immediate postoperative period, to promptly detect any complications.
Choice D reason:
Weighing the client every evening is not directly related to the management of continuous bladder irrigation. While monitoring weight can be part of overall postoperative care, it does not address the specific needs related to TURP and continuous bladder irrigation.
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