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 B
Explanation
Choice A reason:
A BUN level of 8 mg/dL and a creatinine level of 0.7 mg/dL are within normal ranges for a healthy individual without kidney disease. In chronic kidney disease (CKD), we would expect these values to be elevated due to the kidneys' reduced ability to filter waste products from the blood.
Choice B reason:
A BUN level of 45 mg/dL and a creatinine level of 8 mg/dL are significantly higher than the normal range, which is consistent with impaired kidney function seen in CKD. These elevated levels indicate that the kidneys are not effectively filtering urea and creatinine from the blood, leading to their accumulation.
Choice C reason:
A BUN level of 23 mg/dL and a creatinine level of 1.0 mg/dL could be seen in the early stages of CKD. While the creatinine level is within the normal range, the BUN level is slightly elevated, which may suggest a decline in kidney function.
Choice D reason:
A BUN level of 10 mg/dL and a creatinine level of 0.3 mg/dL are both below the normal range. This is an unlikely finding for a patient with CKD, as kidney impairment typically leads to increased levels of these substances in the blood.
Correct Answer is A
Explanation
Choice A Reason:
Administering antibiotics is a primary intervention for AGN when it is caused by a bacterial infection, such as post-streptococcal glomerulonephritis. Antibiotics help eliminate the infection and prevent further damage to the glomeruli.
Choice B Reason:
Encouraging increased fluid intake is not typically recommended for AGN, especially if the client has oliguria or edema, which are common in this condition. Fluid intake may need to be restricted to prevent fluid overload and worsening of hypertension.
Choice C Reason:
Frequent ambulation is not a priority intervention for AGN. While maintaining mobility is important, it does not directly address the renal inflammation or potential complications associated with AGN.
Choice D Reason:
Obtaining weight weekly is important for monitoring fluid status, but it is not the primary intervention. Daily weight measurements are more indicative of fluid retention or loss and are essential for closely monitoring the client's fluid balance.
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