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 B

Explanation

A. Improved wound healing:

While silver sulfadiazine is used to promote wound healing by preventing and treating infections in burn victims, this is not an adverse reaction. This is an intended therapeutic effect of the medication.

B. Allergic reaction in patients with sulfa allergies:

Silver sulfadiazine contains sulfa, and patients who have a sulfa allergy may experience an allergic reaction. This can range from mild skin rashes to severe systemic reactions and is considered a significant adverse reaction.

C. Delayed wound healing:

Silver sulfadiazine is generally used to promote wound healing by preventing bacterial infections. Delayed wound healing is not a common adverse reaction but may occur in some cases due to other underlying factors or if the medication is not effective against certain bacteria.

D. Increased risk of infection:

The primary purpose of silver sulfadiazine is to reduce the risk of infection in burn wounds. An increased risk of infection would indicate a failure of the medication, not an adverse reaction. The correct potential adverse reaction is an allergic response in patients with a known sulfa allergy.

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

Which of the following is a potential adverse reaction to silver sulfadiazine in burn victims?

Correct Answer is B

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

The nurse is doing a focus assessment on a 25-year-old college student who presented to the clinic secondary to fever and lethargy. When recording the findings of the lymph glands, a nurse should note all except:

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