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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason:
Bathroom privileges after premedication are not typically restricted unless the premedication impairs the client's ability to ambulate safely. However, it is important to ensure that the client does not fall or injure themselves due to the effects of the medication.
Choice B reason:
Drinking 8 oz of water is generally not advised immediately before surgery due to the risk of aspiration during anesthesia. Clients are usually instructed to fast, which includes not drinking any liquids, for a certain period before surgery.
Choice C reason:
Preoperative diazepam may be administered 30 minutes before surgery to help reduce anxiety and induce sedation. Diazepam is a benzodiazepine that can calm the client and facilitate a smoother induction of anesthesia.
Choice D reason:
Enema administration is not a standard preoperative procedure for a client undergoing a cholecystectomy unless there is a specific indication. The primary focus is on preventing infection and managing pain.
Correct Answer is D
Explanation
Choice A reason:
Annular lesions are ring-shaped with a clear center, which does not describe a lesion with a wavy border. This term is typically used for lesions like ringworm, which present as circular rashes with normal skin in the center.
Choice B reason:
Circinate lesions are also circular but are not characterized by a wavy border. They are similar to annular lesions but often have a more rounded edge and are associated with conditions like psoriasis.
Choice C reason:
Coalesced lesions refer to multiple lesions that have merged to form a larger one. While they can have irregular borders, 'coalesced' does not specifically describe the wavy nature of the border.
Choice D reason:
Serpiginous lesions have a wavy or snake-like border, which matches the description provided by the nurse. This term is often used for parasitic infections, such as cutaneous larva migrains, which create a trail-like pattern on the skin.
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