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

Answer and Explanation

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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Correct Answer is C

Explanation

Choice A reason:
Adjusting the rate of the bladder irrigant may be necessary if there is an issue with the flow or the amount of fluid, but it is not the first action to take. The nurse must first ensure that there is no mechanical obstruction causing the lack of drainage.

Choice B reason:
Irrigating the catheter could be the next step if checking the tubing does not resolve the issue. However, it is not the first action to take because if there is a kink in the tubing, irrigation will not be effective and could potentially cause harm.

Choice C reason:
The first action the nurse should take is to check the tubing for kinks because this is a common and easily correctable cause of obstruction in catheter drainage. If the tubing is kinked, straightening it may allow urine to drain properly.

Choice D reason:
Notifying the provider is important if the other interventions do not resolve the issue. However, it is not the first action to take. The nurse should first perform basic troubleshooting steps to identify and correct any simple mechanical issues with the catheter system.

A. Mantoux test B. Sputum culture for acid-fast bacillus C. Sputum smear D. Chest x-ray

Correct Answer is B

Explanation

Choice A reason:
The Mantoux test, also known as the tuberculin skin test, is used to detect latent TB infection but is not the most reliable for confirming active pulmonary TB. It can indicate if someone has been infected with TB bacteria, but it cannot differentiate between latent and active TB.

Choice B reason:
A sputum culture for acid-fast bacillus is the gold standard for diagnosing active pulmonary TB. It involves culturing a sample of sputum (phlegm) to see if TB bacteria grow, which confirms the diagnosis. This test is the most definitive and reliable method, although it may take several weeks to obtain results.

Choice C reason:
A sputum smear can detect TB bacteria in sputum samples quickly, but it is less sensitive than a culture. It can miss cases, especially if the bacterial load is low. Therefore, while useful for initial screening, it is not as reliable as a culture for confirming active TB.

Choice D reason:
A chest x-ray can show signs suggestive of TB, such as infiltrates or cavities in the lungs, but it cannot confirm the presence of TB bacteria. It is a supportive diagnostic tool but not definitive for active TB diagnosis.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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