What data collected during an integumentary assessment should cause the nurse to be concerned that a client is at risk for the development of skin cancer? (Select all that apply.)

Age 55 years

Yellow palms of the hands

Light-colored hair

Actinic keratosis on face

Poor skin turgor

Answer and Explanation

Correct Answer : A,C,D

A) Age 55 years:

Advancing age is a risk factor for skin cancer. As individuals age, the cumulative exposure to UV radiation increases, and the skin's ability to repair damage decreases, leading to a higher risk of skin cancer.

B) Yellow palms of the hands:

Yellow palms are typically associated with conditions like carotenemia or jaundice, not skin cancer. This symptom does not indicate an increased risk of developing skin cancer.

C) Light-colored hair:

Individuals with light-colored hair, especially those with fair skin and light eyes, are at higher risk for skin cancer. They often have less melanin, which provides some protection against UV radiation, increasing their susceptibility to damage from the sun.

D) Actinic keratosis on face:

Actinic keratosis is a precancerous skin lesion caused by long-term sun exposure. It is considered a significant risk factor for developing squamous cell carcinoma, a type of skin cancer. Presence of actinic keratosis should prompt careful monitoring and possibly treatment.

E) Poor skin turgor:

Poor skin turgor typically indicates dehydration or aging but is not directly related to an increased risk of skin cancer. It is more of a general indicator of skin and overall health rather than a specific risk factor for cancer.

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Correct Answer is A

Explanation

A. 20 represents the distance you are placed from the chart and 40 represents the distance a normal eye reads the chart:

This is correct. The first number (20) represents the distance in feet the patient is from the Snellen chart. The second number (40) indicates the distance at which a person with normal vision can read the same line. Therefore, 20/40 means that what the patient can read at 20 feet, a person with normal vision can read at 40 feet.

B. 20 represents the distance a normal eye can read and 40 represents the distance your eye reads the chart:

This is incorrect. The first number should represent the distance the patient is from the chart, not the normal eye's reading distance.

C. 20 represents the distance you are placed from the chart and 40 represents the distance your eye reads the chart:

This is incorrect. While the first number is correct (the distance from the chart), the second number should represent the distance a person with normal vision can read the same line, not the patient's distance.

D. 40 represents the distance you are placed from the chart and 20 represents the distance a normal eye reads the chart:

This is incorrect. The standard for visual acuity measurements is that the first number represents the testing distance (usually 20 feet), and the second number represents the distance at which a normal eye can read the line.

A. to prevent further dehydration B. to assist the client to feel more comfortable C. to observe the movement of the thyroid gland D. to promote the nurse-client relationship

Correct Answer is C

Explanation

A. To prevent further dehydration:

While preventing dehydration is important, it is not the primary reason for bringing a cup of water when assessing the thyroid gland. Dehydration is addressed through overall fluid management rather than during a specific thyroid exam.

B. To assist the client to feel more comfortable:

Providing comfort is essential, but bringing a cup of water specifically for comfort during a thyroid exam is not typically necessary. The primary focus of the water in this context is related to the assessment process.

C. To observe the movement of the thyroid gland:

Observing the movement of the thyroid gland during swallowing can help the nurse assess for abnormalities. Having the client drink water allows the nurse to observe the thyroid gland's movement, which can indicate the presence of goiters, nodules, or other irregularities.

D. To promote the nurse-client relationship:

Promoting a good nurse-client relationship is always beneficial, but bringing a cup of water for this specific purpose is not relevant to the physical assessment of the thyroid gland. The water's main purpose is to facilitate the physical examination process.

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What data collected during an integumentary assessment should cause the nurse to be concerned that a client is at risk for the development of skin cancer? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is performing a complete physical examination on a patient. After examining the patient with the Snellen chart, the nurse documented distance vision in both eyes 20/40. The patient asks the nurse what 20/40 means:

Correct Answer is A

Explanation

When the nurse is preparing to assess the thyroid gland of a client with suspected hypothyroidism, why is it important to bring a cup of water to the physical examination?

Correct Answer is C

Explanation

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