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) The patient is unable to see in half of the visual field (same visual field) in each eye:

Homonymous hemianopsia is a condition where there is a loss of vision in the same side of the visual field in both eyes. This occurs due to damage to the visual pathways after the optic chiasm, often from a stroke or brain injury, resulting in the loss of either the right or left visual field in both eyes.

b) The patient can see from one eye but not through the other one:

This description fits a condition called monocular blindness, which is typically caused by damage to the optic nerve before it reaches the optic chiasm. Homonymous hemianopsia involves both eyes and specific visual fields, not complete loss of vision in one eye.

c) The patient is unable to see in half of the visual field (opposite visual field) in each eye:

This option describes bitemporal hemianopsia, which results in loss of vision in the outer (temporal) fields of both eyes and is often due to damage at the optic chiasm. Homonymous hemianopsia involves the same side of the visual field in both eyes, not the opposite visual fields.

d) No visual impairment:

Homonymous hemianopsia is characterized by significant visual impairment, specifically the loss of half the visual field in both eyes on the same side. Therefore, it is incorrect to say there is no visual impairment with this condition.

A. Encourage the client to look at the balance beam B. Have the client wear the same clothing every day. C. Weigh the client at the same time in the morning D. Use the same scale to weigh the client. E. Discuss the client's weight with her after each measurement.

Correct Answer is ["B","C","D"]

Explanation

A) Encourage the client to look at the balance beam:

Encouraging the client to look at the balance beam may help her feel more engaged in the process of weight measurement. This can foster trust and cooperation during what may be a challenging procedure due to her history of Anorexia and Bulimia Nervosa.

B) Have the client wear the same clothing every day:

Consistency in clothing helps to minimize variations in weight measurements that could be attributed to changes in clothing weight rather than actual body weight fluctuations. This practice ensures more accurate and reliable serial weight measurements.

C) Weigh the client at the same time in the morning:

Weighing the client at the same time each day helps to standardize conditions and minimize daily variations due to factors like hydration levels and food intake, providing more accurate serial weight measurements.

D) Use the same scale to weigh the client:

Using the same scale ensures consistency in measurement accuracy. Different scales can yield slightly different readings, which could affect the interpretation of weight trends over time.

E) Discuss the client's weight with her after each measurement:

While discussing weight may be part of the client's care plan, it's not necessarily a standard action during the process of conducting serial weight measurements. The focus during the actual weighing process should be on maintaining consistency and accuracy.

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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 patient is diagnosed with Homonymous Hemianopsia. The nurse expects to find what defects in the visual field of this patient:

Correct Answer is A

Explanation

A 22-year-old female client with a history of Anorexia and Bulimia Nervosa is prescribed serial weight measurements every day. What actions will the nurse take when conducting these serial weights? (Select all that apply.)

Correct Answer is ["B","C","D"]

Explanation

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