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 C
Explanation
Choice A reason:
The statement "HIPAA is a federal law, not a state law" is correct. HIPAA is indeed a federal law that provides national standards to protect the privacy of personal health information.
Choice B reason:
The statement "HIPAA established regulations for individually identifiable health information in verbal, electronic, or written form" is also correct. HIPAA does regulate how individually identifiable health information should be protected and handled across various forms of communication.
Choice C reason:
The statement "Information about a client can be disclosed to family members at any time" indicates a need for further teaching. Under HIPAA, protected health information can only be disclosed to family members under certain conditions, such as when the patient has given permission or when it is directly relevant to the family member's involvement in the patient's care.
Choice D reason:
The statement "A client's address would be an example of personally identifiable information" is correct. Under HIPAA, a client's address is considered personally identifiable information, which is protected and cannot be disclosed without proper authorization.
Correct Answer is C
Explanation
Choice A reason:
Mucositis is an inflammation of the mucous membranes lining the digestive tract, which is commonly associated with chemotherapy and radiation therapy, not directly with opioid use. While it can be a concern for cancer patients, it is not a typical side effect of opioids.
Choice B reason:
Bleeding is not a common side effect of opioid medications. While cancer patients may experience bleeding due to various reasons, including the cancer itself or treatment-related issues, opioids do not typically cause bleeding.
Choice C reason:
Opioid-induced constipation (OIC) is a common side effect of opioid medications due to their action on the gastrointestinal tract. Opioids reduce gastrointestinal motility, leading to constipation, which can progress to impaction if not managed properly. This is a manifestation that nurses should anticipate and manage proactively in clients taking opioid medications for pain management.
Choice D reason:
Diarrhea is not typically associated with opioid use. In fact, opioids are more likely to cause constipation rather than diarrhea. Diarrhea may occur as a result of other treatments or conditions but is not a direct side effect of opioids.
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