When assessing a client's skin, which finding should the nurse report to the healthcare provider?

Large, flat, dark red irregular area on the neck.

Multiple silver striae on the abdomen.

Bluish discoloration of the nailbeds.

Multiple yellow lesions with a grainy surface.

Answer and Explanation

The Correct Answer is A

A.   This finding is most concerning as it could indicate a melanoma, a type of skin cancer that is highly aggressive and potentially fatal. The characteristics of the lesion - large, flat, dark red, irregular - are consistent with a melanoma.
B.   Striae are stretch marks, often caused by rapid weight gain or pregnancy. While they can be unsightly, they are generally not a cause for concern.
C.   Bluish discoloration of the nailbeds can be a sign of cyanosis, which may indicate a lack of oxygen in the blood. However, it could also be caused by other factors such as cold temperatures or poor circulation. While this finding should be investigated further, it is not as urgent as a large, irregular, dark red area on the neck.
D.   These lesions could be xanthelasmas, which are yellow, fatty deposits often associated with high cholesterol levels. While they are not dangerous, they can be a sign of underlying health issues and should be discussed with a healthcare provider.

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Correct Answer is C

Explanation

A. At six weeks post-hysterectomy, a focused assessment that addresses the specific concerns related to the surgery and recovery would be more appropriate. A full physical examination might be too broad for this purpose, although aspects of it might be included if specific issues are identified.
B. A Pap smear is typically not required during a post-surgical follow-up for a hysterectomy unless there is a specific reason to screen for cervical cancer. In many cases, especially if the hysterectomy was for benign reasons and the cervix was removed, Pap smears might not be necessary.
C. This approach is highly relevant for a post-surgical evaluation. Gathering information about the client’s activities since surgery helps assess the recovery process, identify any issues or complications, and provide appropriate advice for ongoing care. Activities might include physical activity levels, adherence to post-surgical instructions, any new symptoms, and overall well-being.
D. A comprehensive review of systems is a thorough approach to identifying any potential issues across various body systems. While this can be useful in some cases, it may be more extensive than necessary for a routine follow-up after a hysterectomy.

A. Measure the degree of skin elasticity. B. Palpate the area for warmth and swelling. C. Determine the client's oxygen saturation. D. Observe the appearance of the nailbeds.

Correct Answer is B

Explanation

A. Skin elasticity is assessed by pinching the skin to see how quickly it returns to its normal position, which is often done to evaluate hydration status or the presence of dehydration. While skin elasticity is an important overall assessment of skin health, it is not directly related to the assessment of erythema.
B. Palpating the erythematous area for warmth and swelling is a crucial follow-up assessment. Erythema (redness of the skin) can be a sign of inflammation or infection, and the presence of warmth and swelling can help determine if the area is inflamed or if there might be an underlying infection.
C. Oxygen saturation measurements assess the level of oxygen in the blood, typically using a pulse oximeter. While oxygen saturation is important for assessing overall respiratory and circulatory health, it is not directly related to evaluating the cause or characteristics of erythema. Therefore, this would not be the most relevant follow-up assessment for a red area on the skin.
D. Observing the appearance of the nailbeds can provide information about overall circulation and oxygenation, but it is not directly related to assessing a localized area of erythema on the skin. Changes in the nailbeds can indicate systemic conditions but would not provide specific information about the erythematous area in question.

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When assessing a client's skin, which finding should the nurse report to the healthcare provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client reports to the healthcare provider's office for a routine post-surgical evaluation six weeks after a hysterectomy. Which history-taking approach should the nurse use to gather the needed information?

Correct Answer is C

Explanation

When inspecting a client's skin, the nurse observes an area of erythema on the arm. Which follow- up assessment should the nurse complete?

Correct Answer is B

Explanation

When assessing a client's level of consciousness, the nurse determines that the client is alert and ambulatory, but confused. Which follow- up assessment should the nurse complete next?

Which assessment technique should the nurse use to confirm the presence of papilledema in a client with a rapidly decreasing level of consciousness?

The nurse examines a client's abdomen. Which finding indicates an abnormal response when palpating the spleen?

The nurse examines a client's abdomen. Which finding indicates an abnormal response when palpating the spleen?

In assessing a client's nailbeds, the nurse notes that the angle between the nail and the nailbed is 200 degrees. Which action should the nurse take?

The nurse is examining the abdomen of an older male client who expresses suprapubic tenderness on palpation. The client reports that it sometimes feels like there is still pressure in that area after urination. Which additional finding should the nurse expect with continued interview of the client?

A client who recently underwent a routine surgical procedure made a dinic appointment. To elicit the most information, which question is best for the nurse to ask this client?

While assessing a client, the nurse observes that the client has a frequent productive cough. What follow-up assessment should the nurse evaluate first?