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?

Answer and Explanation

The Correct Answer is C

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:
Understanding how a client handles stress is important because stress can exacerbate many skin conditions. This question is appropriate and does not require intervention. Stress management techniques may be beneficial for the client and could be a part of the care plan.

Choice C reason:
Inquiring about the emotional impact of a skin condition is a critical aspect of holistic care. Skin conditions can significantly affect a person's self-esteem and emotional well-being. This question is empathetic and helps the nurse understand the client's experience, thus no intervention is needed.

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: The use of erythropoiesis-stimulating agents (ESAs) is indicated for anemia due to chemotherapy¹. However, the client's hemoglobin (Hgb) level is 12.1 g/dL, which is within the normal range (normal: 12-15.5 g/dL for women). Therefore, administering an ESA is not indicated based on the Hgb level provided.

Choice B reason: A diet with increased protein can be beneficial for patients undergoing chemotherapy as it helps in tissue repair and immune system function. However, the client's albumin level is 4.5 g/dL, which falls within the normal range (normal: 3.4-5.4 g/dL), suggesting adequate protein intake. Thus, there is no indication that the client requires an increased protein diet based on the albumin level provided.

Choice C reason: The client's white blood cell (WBC) count is 1,400/mm³, which is below the normal range (normal: 4,500-11,000/mm³). This condition, known as leukopenia, significantly increases the risk of infection³. Therefore, the nurse should prioritize monitoring for signs of infection and implementing infection control measures.

Choice D reason: The client's platelet count is 170,000/mm³, which is within the normal range (normal: 150,000-450,000/mm³). Although cisplatin can cause thrombocytopenia, the current platelet count does not indicate an increased risk for bleeding⁴. Therefore, this choice is not correct based on the platelet count provided.

A. Abdominal distention B. Request for a cup of tea and some toast C. Hypoactive bowel sounds in two quadrants D. Passage of flatus

Correct Answer is D

Explanation

Choice A reason:
Abdominal distention can be a sign of delayed return of peristalsis or ileus, especially when accompanied by other symptoms such as nausea, vomiting, or lack of bowel movement. It is not typically a sign that peristalsis is returning.

Choice B reason:
A request for a cup of tea and some toast may indicate that the client is feeling better and is hungry, which can be a good sign. However, it is not a definitive clinical indicator of the return of peristalsis. The desire to eat does not necessarily mean that the digestive system is ready to process food.

Choice C reason:
Hypoactive bowel sounds in two quadrants may indicate that peristalsis is present but weak. While this could be a sign that peristalsis is starting to return, it is not as strong an indicator as the passage of flatus or stool.

Choice D reason:
The passage of flatus is a clear sign that peristalsis is returning. It indicates that gas is moving through the intestines, which is a function of peristalsis. This is often one of the first signs that the gastrointestinal system is recovering after surgery.

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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?

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following findings should indicate to the nurse that the client's peristalsis is returning?

Correct Answer is D

Explanation

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